LIBRARY OF CONGRESS, 



fljrap. (Sopjrtgfyi If u, 

ShelfRI.l.jlL 

3f 

UNITED STATES OF AMeI?CA. 



DISEASES OF THE EAR 



A TEXT-BOOK 

FOR PRACTITIONERS AND STUDENTS 

OF MEDICINE 



BY 

EDWARD BRADFORD DENCH, Ph. B., M. D. 

PROFESSOR OF DISEASES OF THE EAR IN THE BELLEVUE HOSPITAL MEDICAL COLLEGE ; 

AURAL SURGEON, NEW YORK EYE AND EAR INFIRMARY ; FELLOW OF THE 

AMERICAN OTOLOGICAL SOCIETY ; OF THE NEW YORK ACADEMY 

OF MEDICINE ; OF THE NEW YORK OTOLOGICAL SOCIETY ; 

OF THE NEW YORK COUNTY MEDICAL SOCIETY, ETC. 




WITH EIGHT COLORED PLATES AND 
ONE HUNDRED AND FIFTY-TWO ILLUSTRATIONS IN THE TEXT 



NEW YOR K 

D. APPLETON AND COMPANY 

1894 




\ 






Copyright, 1894, 
By D. APPLETON AND COMPANY. 



Electrotyped and Printed 
at the appleton press, u. s. a. 



PREFACE. 



In the preparation of the present work it has been my aim 
to adapt it to the needs both of the general practitioner and 
the special surgeon. For this reason minute pathology has 
not been considered extensively. 

In detailing the various manipulative procedures, I have 
preferred to err on the side of prolixity, for the benefit of 
those not familiar with the subject. It has also been my 
purpose to keep constantly before the reader, the fact that 
many diseases of the ear should not be considered by them- 
selves, for the reason that they are often local manifestations 
of systemic condition. 

Many works upon otology have failed to emphasize the 
importance of a thorough functional examination ; and none 
have placed the results of recent investigations at the disposal 
of the reader in such a manner as to enable him to use them 
in diagnosis. In consequence, I have written at length upon 
this subject. 

In advocating operative procedures upon the middle ear 
and in devoting much space to the subject of middle-ear 
operations, I am aware that I shall not have the support of 
many distinguished colleagues. As a careful reading of the 
chapter will show, I have written from personal experience ; 
and if my results differ from those of other operators, I sug- 
gest that the selection of cases suitable for operation, accord- 
ing to the principles detailed in previous chapters, may 
account for the favorable outcome of the operations. 

In illustrating the gross pathological lesions of the con- 
ducting mechanism and the various manipulative measures 
instituted for their relief, I have adopted the plan of showing 
the auricle, meatus, and middle ear in the same drawing. The 
drawings are of natural size, and the technique of the various 
procedures seems to be made more clear in this manner, than 
by any other method. 

(iii) 



iv PREFACE. 

In the colored plates of the membrana tympani, the adja- 
cent portion of the meatus is also shown, thus reproducing as 
completely as possible the picture seen upon speculum exami- 
nation, and rendering- the relative position of the parts more 
intelligible. In this connection I desire to express my indebt- 
edness to Dr. \V. A. Holden for the careful manner in which 
he prepared these plates from clinical cases. Without his aid, 
these illustrations would have been impossible. 

The absence of extensive bibliographical citations may 
seem a defect, but in a work intended as a clinical guide, a 
complete bibliography would be impossible, and unless com- 
plete it would be useless. No attempt has been made, there- 
fore, to collate the entire literature of any subject, and the 
citations have been limited to those necessary to give indi- 
vidual investigators the proper credit for their researches. 

It gives me pleasure to thank the W. F. Ford Surgical 
Instrument Company for the care which they have bestowed 
upon the illustrations of various instruments and appliances 
which appear in this volume. 

17 West 46TH Street, New York City, 
October 10, i8g4. 



CONTENTS. 



SECTION I. 
THE ANATOMY AND PHYSIOLOGY OF THE EAR. 

CHAPTER I. 

PAGES 

The Anatomy of the Ear 3-47 

The auricle — The external meatus — The bony meatus — The tym- 
panic cavity — The ossicles — The intratympanic ligaments — The 
membrana tympani — The epithelial investment of the conducting 
apparatus — Intratympanic folds — The muscles — The arteries — The 
veins — The lymphatics — The nerves — The bony labyrinth — The 
membranous labyrinth — The saccule and utricle — The membranous 
cochlea — The vascular supply of the labyrinth — The auditory nerve. 

CHAPTER II. 
The Physiology of the Ear . . ■ 48-72 

Sound — Function of the membrana tympani — Function of the ossi- 
cles — Function of the muscles — Function of the cochlea and semi- 
circular canals — Effect of tympanic changes upon the labyrinth — 
Effect of stimuli upon the auditory nerve — Reflex phenomena — 
Secondary phenomena — Hyperesthesia and paresthesia. 

CHAPTER III. 
Physical Examination 73-141 

Preliminary observations — Source of illumination — The Reflecting 
Mirror — Specula — Technique of Examination — Appearance of the 
meatus and membrana tympani — Obstacles to examination — Tym- 
panic topography — Politzerization — Catheterization — Auscultatory 
sounds— Obstacles to catheterization — Dangers of catheterization — 
The examination of the nose and throat — The history. 

CHAPTER IV. 
Functional Examination 142-170 

Quantitative tests — Qualitative tests — Bone conduction — Differential 
diagnosis — Precautionary measures — Irregular phenomena — Special 
tests — Galvanic reaction of the auditory nerve. 

(v) 



vi CONTENTS. 

SECTION II. 
DISEASES OF THE CONDUCTING APPARATUS. 

/. DISEASES OF THE AURICLE. 
CHAPTER V. 

PAGES 

Congenital Malformations of the Auricle . . . 173-182 

Deformities of particular parts of the auricle — Deformity or malpo- 
sition of the entire auricle — Auricular appendages — Polyotia. 

CHAPTER VI. 
Wounds and Injuries of the Auricle 183-186 

Contused, lacerated and incised wounds — The effect of intense cold 
— Burns — Injuries due to the action of chemical substances. 

CHAPTER VII. 
Cutaneous Diseases of the Auricle ..... 187-199 

Intertrigo— Eczema — Pemphigus — Herpes — Syphilis — Lupus. 

CHAPTER VIII. 
Inflammatory Affections of the Auricle .... 200-205 

Perichondritis — Erysipelas — Abscess — Othematoma — Thickening 
of the lobule — Ossification — Gangrene. 

CHAPTER IX. 

Benign Tumors of the Auricle 206-212 

Fibroma — Lipoma — Atheroma — Angioma — Cystoma — Papilloma. 

CHAPTER X. 
Malignant Tumors of the Auricle and of the Meatus . 213-216 

Epithelioma — Sarcoma. 

II. DISEASES OF THE EXTERNAL AUDITORY MEATUS. 

CHAPTER XI. 
Circumscribed External Otitis 217-237 

Acute Circumscribed External Otitis or Furuncle. ^Etiol- 
ogy — Pathology — Symptomatology — Diagnosis — Prognosis — Treat- 
ment — Bloodletting— Cold — Instillations — Heat — Incision — Inter- 
nal medication. Chronic Circumscribed External Otitis. 
Significance in diagnosis of mastoid inflammation. 

CHAPTER XII. 

Diffuse External Otitis 238-266 

Chronic Diffuse External Otitis. ^Etiology — Pathology — 
Superficial — Cellular — Desquamative — Parasitic — Consecutive — 



CONTENTS. vii 

PAGES 

Symptomatology — Diagnosis — Prognosis — Treatment of the various 
varieties of the disease. Acute Diffuse External Otitis. 
Etiology — Dependence upon the chronic form — Pathology — Symp- 
tomatology — Diagnosis — Involvement of middle ear — Prognosis — 
Treatment — Local depletion — Irrigation — Cold — Incision. Croup- 
ous and Diphtheritic External Otitis. Hemorrhagic 
External Otitis. 

CHAPTER XIII. 
Impacted Cerumen 267-278 

^Etiology — Pathology — Symptomatology — Direct and reflex phe- 
nomena — Diagnosis — Prognosis — Treatment — Use of the syringe — 
Use of the curette. 

CHAPTER XIV. 
Foreign Bodies in the Canal . . . . • . . . 279-284 

^Etiology — Pathology — Symptomatology — Diagnosis — Prognosis — 
Treatment — Removal through the natural passage — Removal by 
external incision. 

CHAPTER XV. 
Exostosis of the External Auditory Meatus . . . 285-290 

^Etiology — Pathology — Symptomatology — Diagnosis — Prognosis — 
Treatment. 

CHAPTER XVI. 
Wounds and Injuries of the Membrana Tympani . . 291-295 

yEtiology — Pathology — Symptomatology — Diagnosis — Prognosis — 
Treatment. 



III. DISEASES OF THE MIDDLE EAR. 

CHAPTER XVII. 
Tubal Congestion, or Tubal Catarrh 300-312 

^Etiology — Pathology — Symptomatology — Diagnosis — Physical ex- 
amination — Functional examination — Prognosis — Treatment — In- 
flation — Dilatation — Medicated vapors — Prophylaxis. 

CHAPTER XVIII. 
Tubo-tympanic Congestion.— Tubo-tympanic Catarrh . 313-322 

^Etiology — Pathology — Symptomatology — Diagnosis — Physical Ex- 
amination — Functional examination — Prognosis — Treatment — In- 
flation — Incision — Internal medication. 

CHAPTER XIX. 
Acute Catarrhal Otitis Media 323-335 

^Etiology — Pathology — Superficial structures alone affected — Symp- 
toms in adults — Symptoms in children — Inspection of discharge — 
Diagnosis — Physical examination — Functional examination — Prog- 
nosis — Treatment — Depletion — Dry heat — Instillations — Incision- 
Irrigation — Topical applications. 



Vlll 



CONTENTS. 



CHAPTER XX. 

PAGES 

Acute Purulent Otitis Media 336-350 

Etiology — Pathology — Involvement of the connective tissue in the 
vault of the tympanum — Secondary involvement of the lower por- 
tion of the cavity — Extension to bony structures — Symptomatology 
— Evidences of mastoid involvement — Evidences of extension to 
the cranial cavity — Diagnosis — Physical examination — Bulging of 
membrana ilaccida — Functional examination — Prognosis — Subse- 
quent functional condition — Chronic purulent otitis — Mastoid and 
intracranial involvement — Fatal cases — Treatment — Depletion — 
Early incision — Irrigation — Abortive treatment when mastoid symp- 
toms appear — Treatment of persistent discharge — Drainage. 

CHAPTER XXI. 
Chronic Catarrhal Otitis Media 351-387 

General considerations concerning pathological characteristics sep- 
arating the cases into two classes. Chronic Hypertrophic Oti- 
tis Media. Etiology — Influence of repeated attacks of congestion 
— Unresolved acute otitis — Affections of the upper air passages — 
Sex — General condition — Heredity — Pathology — Tympanic changes 
— Changes in the drum membrane — In the Eustachian tube — In the 
tympanic ligaments — In the labyrinth — Symptomatology — Bilateral 
involvement — Intermittent character of the subjective noises and 
impairment of hearing — Reflex pain referred to the region of lingual 
tonsil — Diagnosis — Physical examination — Altered position and den- 
sity of membrana tympani — Changes in the apparent breadth of 
malleus handle from rotation — Effusion — Functional examination — 
Impairment for voice greater relatively than for sharp sounds — 
Changes in the limits of audition — Condition of organ secondarily 
involved — Prognosis — Duration of affection — Condition of upper air 
passages — Degree of bilateral involvement — Age — Secondary scle- 
rotic changes — Treatment — Treatment of the upper air passages — 
Surgical measures and topical applications — Of the Eustachian tube 
— Inflation — Irrigation — Dilatation — Topical applications — Of the 
middle ear — Simple inflation — Medicated vapors — Absorption or 
evacuation of effusion — Lavage of tympanum — Tenotomy of tensor 
tympani — Mechanical support in relaxation — Surgical procedures. 
Chronic Hyperplastic Otitis Media. ^Etiology — Secondary 
to acute inflammations of tympanum or to hypertrophic inflamma- 
tion — Idiopathic disease resulting from systemic causes — Occurrence 
in one ear as the result of changes in the opposite organ — Pathology 
— Sclerotic changes in the tympanic connective tissue — Deposit of 
new connective tissue — Changes in the membrana tympani — Depos- 
its about oval and round windows — Tension anomalies causing rota- 
tion of malleus upon its long axis — Changes in the tympanic vault — 
Labyrinthine involvement — Condition of the Eustachian tube — 
Symptomatology — Insidious development — Subjective noises with- 
out impairment of hearing — Local and reflex pain — " Auditory fa- 
tigue " — Neurasthenic manifestations — Diagnosis — Physical exam- 
ination — Normal appearance of drum membrane — Atrophy of mem- 
brane — Malposition of ossicles — Appearance of membrana flaccida 
in cases secondary to a hypertrophic process — Functional examina- 
tion—Variation in lower tone limit — Bone conduction — Lateraliza- 
tion of tuning fork — Determination of relative amount of tympanic 
and secondary labyrinthine involvement in "mixed" cases by means 
of tuning forks — Changes in upper tone limit and its significance — 
Prognosis — Spontaneous cessation of the affection — Effect of mental 
and physical exertion — Climatic influence — Age — Treatment — Of 
tympanum and tube — Passive motion — Massage — Surgical measures 
— Of labyrinth — Internal medication — Effect of treatment of middle 
ear upon the labyrinth — Hygienic measures. 



CONTENTS. ix 



CHAPTER XXII. 

pages- 
Chronic Purulent Otitis Media 388-415 

yEtiology — Development from an acute catarrhal or acute purulent 
inflammation — Tuberculosis — Syphilis — Pathology — Necrosis of 
connective tissue and osseous structures — Caries of incus — Cause of 
its frequent occurrence — Labyrinthine involvement — Changes in the 
mastoid — Cholesteatoma — Symptomatology — Discharge — Variations 
in the amount of discharge — Occurrence of aspergillus — Facial pa- 
ralysis — Presence of granulation tissue — Secondary labyrinthine in- 
volvement — Diagnosis — Physical examination — Classification of con- 
ditions usually found upon inspection and their individual signifi- 
cance — Caries — Use of probe — Significance of granulation tissue — 
Displacement of the ossicles — Auscultatory signs — Functional exam- 
ination — Variation in tone limits — Effect on upper tone limit — Bone 
conduction — Electrical reaction — Evidences of mastoid involvement 
— Prognosis — Probable effect upon audition — Cessation of discharge 
— Danger to life — Treatment — Use of syringe — Other methods of 
cleansing — Treatment of the upper air passages — Instillations — 
Powders — Removal of exuberant granulation tissue — Irrigation of 
vault of tympanum — Operative procedures — Statistics of operations 
— Treatment after operation — Internal medication. 

CHAPTER XXIII. 
Otitis Media Purulenta Residua 416-431 

Acute Type. ^Etiology — Identical with that of acute inflamma- 
tion of the normal tympanum— Pathology — Hyperemia of exposed 
lining of tympanum — Serous effusion — Becomes purulent by infec- 
tion through canal — Encysted effusion — Bony necrosis with devel- 
opment of chronic discharge — Symptomatology — Interference with 
function — Discharge — Secondary external otitis — Facial paralysis 
— Diagnosis — Physical examination— Serous discharge — Exfoliation 
of superficial epithelium — Thickening of remnant of drum mem- 
brane — Signs of mastoid involvement — Prognosis — Mild cases — 
Severe cases with retention of pus — Treatment — Mild cases — Asep- 
sis — Topical applications — Treatment of upper air passages — Re- 
moval of dead bone if present to prevent recurrent attacks — Severe 
cases — Incision of membrana flaccida with cupping — Irrigation — 
Cold to mastoid. Chronic Type. Condition one of increased 
tension — Secondary effects on labyrinth — Pathology — Classification 
of conditions found in these cases — Symptomatology — Interference 
with function — Presence of inspissated secretion — Cholesteatoma — 
Pain in mastoid due to sclerotic changes — Diagnosis — Necessity of 
combining physical conditions with data obtained by functional ex- 
amination — Functional examination — Evidences of increased tension 
in conducting mechanism — Labyrinthine involvement — Determina- 
tion of the degree to which perceptive and conducting mechanism 
is affected — Prognosis — Spontaneous improvement — Age — Influence 
of labyrinthine involvement upon the prognosis — Recent and chronic 
cases — Treatment — General measures — Attention to upper air pas- 
sages and Eustachian tube — Prophylaxis against otomycosis — Surgi- 
cal treatment — Effect of treatment upon function of opposite ear. 

IV. DISEASES OF THE MASTOID PROCESS. 

CHAPTER XXIV. 

The Anatomy of the Mastoid Process 432-438 

Variations in presence and location of pneumatic spaces — Location 
of antrum — Relations between superficial landmarks and cranial 
contents — Topographical variations dependent upon age. 



CONTENTS. 



CHAPTER XXV. 

PAGES 

Inflammation of the Mastoid Process 439-452 

./Etiology — Secondary to middle-ear inflammation — Idiopathic cases 
— Pathology — Sclerotic changes — Caries and necrosis — Purulent 
inflammation — Avenues of exit of secretion — Intracranial complica- 
tions and channels of infection — Possibility of infection through 
outer surface of squama — Cholesteatoma — Symptomatology — Pain 
— Temperature not characteristic — Cessation of discharge — Evi- 
dences of intracranial involvement — Evidences of extension of 
thrombus from sinus into internal jugular vein — Diagnosis — Local 
tenderness — Method of eliciting symptom — Involvement of meatus 
close to membrana tympani — Evidences of external rupture — Of 
rupture into digastric fossa — Prognosis — Importance of early recog- 
nition — Chronic cases — Influence of diathetic conditions — Gravity 
of operative measures — Treatment — Free drainage through canal — 
Cold to mastoid — Irrigation of canal — Objection to Wilde's incision 
— Early and radical operation. 

CHAPTER XXVI. 
Intracranial Complications of Tympanic Inflammation . 453-462 

Otitic Meningitis. Manner in which inflammation extends to 
meninges — Symptomatology — Variations dependent upon location 
of lesion — Ocular symptoms — Diagnosis — Temperature — Headache 
— Vomiting — Prognosis — Advisability of operative interference — 
Treatment — Cold applications — Internal medication — Surgical treat- 
ment. Sinus Thrombosis. Avenues of infection — Extension to 
internal jugular — Secondary deposits — Symptomatology — Rigors and 
sweating — Intermittent temperature — General sepsis — Evidences of 
secondary deposits — Diagnosis — Value of frequent thermometric ob- 
servations — General condition of patient — Prognosis — Apparent re- 
covery — Latent cerebral deposits — Treatment — Operative treatment 
— Medication — Alimentation. Extradural Abscess. Nature of 
the process — Symptomatology — Localized headache — Temperature 
changes — Mental condition — Prognosis — Latent deposits — Sponta- 
neous evacuation — Value of operative treatment — Treatment — Ne- 
cessity of surgical interference. Cerebral Abscess. Origin — Site 
— Latent deposits — Aseptic abscesses — Symptomatology — Depend- 
ent upon location — Constitutional symptoms — Asthenia — Sleep- 
lessness — Temperature — Diagnosis — General asthenic symptoms — 
Sleeplessness — Low temperature — Difficulties in diagnosis due to 
complicating lesions — Prognosis — Natural progress when not inter- 
fered with — Proper time for surgical interference — Results of opera- 
tive treatment — Treatment — Evacuation by operation. 



SECTION III. 
SURGERY OF THE CONDUCTING APPARATUS. 

CHAPTER XXVII. 
Middle-ear Operations 465-514 

Preliminary Preparations. Instruments — Form — Construction 
— Sterilization — Field of operation — Necessity of asepsis — Method 
of securing an aseptic condition of the parts — Anaesthesia — Limita- 
tions of local anaesthesia — Conditions demanding general ansesthe- 
sia — Position of the patient — Advantages of elevation of head and 
shoulders. Classification of Operations. I. Operations upon 
the Membrana Tympani — Myringotomy for evacuation of fluid — 



CONTENTS. xi 



For depletion — For exploration — Partial myringectomy — Multiple 
incisions — Plicotomy. II. Operations involving Section of Intra- 
tympanic Tissues — Tenotomy of the tensor tympani — Methods of 
operating — Division of the anterior ligament of the malleus — Divi- 
sion of adhesions in suppurative and nonsuppurative cases. III. 
Operations involving the Ossicular Chain — Excision of a portion of 
the manubrium — Disarticulation and mobilization of the stapes — 
Plastic operations — Removal of the ossicles — Technique when the 
membrana tympani is intact — Treatment after operation — Reaction 
following operation — Reproduction of the membrana tympani — 
Technique when membrane is partially destroyed — Haemorrhage 
during operation — Difficulty of securing the remnant of the incus — 
Curetting of tympanum after removal of ossicles — Subsequent treat- 
ment — Details of technique of disarticulation at the incudo-stape- 
dial joint and removal of the incus — Frequency of caries of incus — 
Control of haemorrhage — Possible accidents — Stacke's operation — 
Stapedectomy — With intact drum membrane — With drum mem- 
brane partially destroyed — Statistics of author's operations showing 
the effect upon the function of audition in cases operated upon. 

CHAPTER XXVIII. 
The Mastoid Operation 515-526 

Instruments — Preparation of field of operation — Incision — Separa- 
tion of sterno-mastoid muscle — Removal of cortex — Removal of 
softened bone — Accidents during operation — Opening of lateral 
sinus — Treatment — Laceration of dura — Treatment — Dressing — 
After-treatment — Technique of operation in young children — Tech- 
nique in mastoid sclerosis — The operation for cholesteatoma — Berg- 
mann's operation. 

CHAPTER XXIX. 

The Surgical Treatment of the Intracranial Compli- 
cations of Aural Suppuration . . .' . . 527-533 

Incision for exposure of sinus, roof of tympanum, and cerebellum — 
Treatment of sinus thrombosis — Ligation of internal jugular — Treat- 
ment of epidural abscess — Probable location of abscess — Operation 
— After-treatment — Treatment of cerebral abscess — Location of ex- 
ploratory opening in skull — Technique of operation — Exploration 
of epidural space — Exposure of brain — Exploratory puncture of 
cerebral substance — Evacuation of ventricular fluid — Exploration of 
cerebellum — Site of exploratory opening — After-treatment of brain 
abscess — Treatment of purulent meningitis — Primary operation on 
mastoid — Exposure of tympanic roof— Exposure of sinus — Dressing. 



SECTION IV. 

DISEASES OF THE PERCEPTIVE MECHANISM. 

Introductory Remarks . . 537-540 

Character of auditory impairment — Comparative value of physical 
and functional examination — Importance of complete history— Lo- 
cation of the pathological process. 

CHAPTER XXX. 
Anaemia of the Labyrinth. . 541-543 

yEtiology — Profuse haemorrhage — Constitutional conditions — Symp- 
tomatology — Functional impairment — Subjective noises — Disturb- 



xii CONTENTS. 



ances of static function — Diagnosis — Physical examination — Func- 
tional examination — Tone limits often preserved or upper tone limit 
may be lowered — Deficient bone conduction — Genera] anaemia — 
Prognosis — Dependent upon cause — Treatment — Stimulants — Ton- 
ics — Drugs to be avoided. 

CHAPTER XXXI. 
Hyperemia of the Labyrinth 544-547 

.Ktiology — General condition — Occupation — Concussion — Acute or 
chronic venous engorgement — Pathology — Dilatation of veins — 
Extravasation — Serous transudation — Symptomatology — Variations 
in degree and persistence of the manifestations — Diagnosis — Ab- 
sence of definite physical signs — Functional examination — Preserva- 
tion of lower tone limit — Upper tone limit reduced — Impairment of 
bone conduction — Prognosis — Varies with duration and degree of 
process — Treatment — Acute cases — Depletion — Rest — Occlusion of 
canal — Pilocarpine — Chronic cases — Counter-irritation — Pilocarpine 
and the method of its administration — General hygienic rules. 

CHAPTER XXXII. 
Labyrinthine Hemorrhage 548-550 

/Etiology — Concussion — Direct traumatism — Blood conditions — 
Changes in the walls of the blood vessels — Diatheses — Pathology — 
Extravasation — Subsequent changes — Symptomatology — Prodro- 
mata — Sudden access of symptoms — Symptoms usually severe — 
Gradual abatement of manifestations — Recurrence — Diagnosis — 
Value of clinical history — Functional examination — Absence of 
bone conduction — Absolute deafness or great auditory impairment 
— Upper tone limit reduced —Occasional disturbances of lower tone 
limit — Prognosis — Varies with the severity of haemorrhage — Static 
function usually restored— Treatment — Acute stage — Depletion — 
Rest — Revulsives — Chronic stage — Reduction of labyrinthine pres- 
sure — Prophylaxis. 

CHAPTER XXXIII. 
Labyrinthine Embolism and Thrombosis .... 551-552 

/Etiology — Metastasis — Inflammation of contiguous structures — Pa- 
thology — Results in local anaemia — Local necrosis — Inflammation — 
Symptomatology — Function of organ usually not much disturbed — 
— Spontaneous improvement — Prognosis — Condition not progressive 
— Treatment — Removal of cause — Reduction of labyrinthine pres- 
sure — Relief of subjective symptoms — Stimulation of impoverished 
nerve tissue. 

CHAPTER XXXIV. 
Specific Inflammation of the Labyrinth .... 553-556 

/Etiology — Hereditary or acquired syphilis — Pathology — Chronic 
inflammatory changes — Hypertrophy — Changes in walls of vessels 
— Necrosis — Symptomatology — Sudden access in acquired form — In- 
vasion less sudden in hereditary cases — Diagnosis — Physical exami- 
nation — Recognition of concomitant tympanic disease — Functional 
examination — Deficient bone conduction — Lowering of upper tone 
limit — Differential diagnosis in " mixed " form — Prognosis — Influ- 
ence of heredity — Age of local process — Spontaneous quiescence — 
Treatment — Antisyphilitic medication — Pilocarpine — Iodide of po- 
tassium — Strychnine in advanced cases — Tonic treatment in heredi- 
tary cases. 



CONTENTS. xiii 

CHAPTER XXXV. 

PAGES 

Inflammation of the Labyrinth secondary to Chronic 
Suppurative and Nonsuppurative Inflammation of 
the. Tympanum 557-568 

Pathology — Inflammatory changes — Atrophic changes — Extension 
of inflammation from tympanum — Condition of oval and round win- 
dow — Results of suppuration — Functional disturbances — Symptom- 
atology — Subjective noises — Significance of disappearance of tin- 
nitus — Vertigo — Sympathetic involvement of opposite ear — Diag- 
nosis — Physical examination — Absence of physical signs in certain 
cases — Value of inspection in residual purulent cases — Functional 
examination — Evidences of obstruction to sound conduction — Ne- 
cessity of repeated examinations — Determination of relative impor- 
tance of tympanic and labyrinthine lesion — Electrical tests — Im- 
portance of examination upon both sides to determine secondary 
involvement of apparently healthy organ — Prognosis — Residual 
purulent cases usually progress but slowly or not at all — Dangers of 
sympathetic involvement — Treatment — Relief of cause in middle 
ear — Preservation of organ involved secondarily — Special measures 
directed toward labyrinth — Pilocarpine — Strychnine — Specific treat- 
ment — Persistent stimulation by sonorous vibrations — Relief of 
subjective noises — Treatment of the upper air passages — Danger of 
treating middle ear in advanced cases. 

CHAPTER XXXVI. 

Acute Inflammation of the Labyrinth secondary to 

Acute Purulent Otitis Media 569-573 

^Etiology — Ordinary causes of acute purulent otitis media — Viru- 
lence of process — Pathology — Tissue necrosis — Avenues of infection 
— Infection of cranial contents — Obliteration of labyrinth from de- 
posit of new tissue — Symptomatology — Not characteristic in young 
subjects — Evidences of labyrinthine infection in adults — Importance 
of facial paralysis as a symptom — Disturbance of static function — 
Retrogression of symptoms — Haemorrhage — Permanent impairment 
of audition — Diagnosis — Physical examination — Not characteristic 
of labyrinthine involvement — Evidences of caries of internal tym- 
panic wall — Functional examination in children unsatisfactory — In 
adults — Upper tone limit much lowered — Bone conduction absent 
or greatly reduced — Vertigo — Prognosis — Unfavorable for complete 
restoration of function — Often fatal in children — In adults not as 
great a menace to life — Danger of absolute deafness less common in 
adults — Danger of causing deaf-mutism in children — Treatment 
— Prophylaxis against infection by asepsis from the first— Relief 
of tinnitus — Procedures to combat extension to meninges — Cold 
locally — Purgation — Value of pilocarpine after acute stage has been 
passed. 

CHAPTER XXXVII. 

Involvement of the Perceptive Mechanism in the Acute 

Infectious Diseases 574-580 

Introductory remarks — Direct infection of labyrinth — Concomitant 
middle-ear inflammation — Pathology — Inflammatory changes — In- 
crease of tension by effusion — Occlusion of vestibular and cochlear 
aqueducts — Symptomatology — Impairment of function — Tinnitus — 
Influence of age of patient upon manifestations — Resultant mutism 
in children — Diagnosis — Simple if middle ear is normal — Determi- 
nation of labyrinthine lesion if tympanum is also affected — Value 
of functional examination in differential diagnosis — " Tone gaps " 



xiv CONTENTS. 

PAGES 

— Prognosis — Not grave in recent cases — More amenable to treat- 
ment in children than in adults — Treatment — Reduction of labyrin- 
thine pressure by pilocarpine — Strychnine in chronic cases — Value 
of persistent education of power of audition. Effect of i i.rtain 
Particular Diseases of this Class. Mumps. Metastatic infec- 
tion of labyrinth — Prognosis excellent in cases subjected to medica- 
tion at an early period. Typhus and Typhoid Fever. Probably 
i causes changes in cortical centres — Usually disappear during conval- 
escence. Epidemic Influenza ; Diphtheria. Probable involve- 
ment of nerve trunk — Impairment in audition for middle portion 
of musical scale — Tone limits unchanged — Galvanic hyperesthesia 
— Bone conduction not lost, but reduced — Treatment directed toward 
improving general condition — Value of strychnine after acute stage. 
Epidemic Cerebrospinal Meningitis. Pathology — Extension 
to labyrinth through aqueducts — Inflammatory changes — Extravasa- 
tion — Deposit of new tissue — Secondary invasion of tympanum — 
Symptomatology — Vertigo — Severe tinnitus — Hyperacusis — Para- 
lytic symptoms — Diagnosis — Physical examination — Negative unless 
tympanum is secondarily involved — Functional examination — Pro- 
found impairment of audition — Upper tone limit greatly reduced as 
a rule — Exceptions — Effect of hypersesthesia on the perception of 
low notes — Bone conduction almost or entirely wanting — Prognosis 
— Complete deafness in severe cases — Significance of disappearance 
of tinnitus — Danger of mutism in children — Treatment — Prophy- 
laxis impossible — Local depletion and catharsis in early stages — 
Pilocarpine valuable after acute stage — Cases of long standing — 
Strychnine — Value of systematic exercise of auditory function by 
the use of conversation tube, etc. 



CHAPTER XXXVIII. 

Involvement of the Perceptive Mechanism in Acute 

Meningitis 581-585 

Pathology — Labyrinthine lesion — Involvement of nerve trunk — 
Cortical lesions — Symptomatology — Variations due to location of 
lesion — In the labyrinth — Subjective noises — Vertigo — Impaired 
audition — Affecting nerve trunk — Interference with perception of 
middle notes of musical scale — Limits of audition normal — Signifi- 
cance of unilateral impairment — Cortical lesion — Bilateral impair- 
ment — Word deafness — Later symptoms — Diagnosis — Physical ex- 
amination — Negative frequently — Importance of rupture of mem- 
brane in traumatic cases — Functional examination — Characteristics 
of labyrinthine lesion — Of lesions of nerve trunk — Of cortical in- 
volvement — Value of electrical tests — Prognosis — Treatment — Acute 
stages — Pilocarpine in later stages — Iodide of potassium — Strych- 
nine — Exercise of auditory function. 

CHAPTER XXXIX. 

The Effect of Diseases of the General Nervous Sys- 
tem upon the Perceptive Mechanism .... 586-588 

Cortical Lesions. Bilateral involvement — Word deafness — Audi- 
tory hallucinations — Intermittent tinnitus. Tabes Dorsalis. De- 
generation of nerve trunk — Galvanic hyperesthesia — Perception of 
middle notes impaired — Torpidity of nerve in later stages. Lesions 
of Vestibular Nerve and of Cerebellum. Disturbance of equi- 
librium — Diagnosis — Dependent upon general rather than special 
symptoms — Treatment — Value of bromides — Strychnine — Antisyph- 
ilitic medication. 



CONTENTS. xv 



SECTION V. 

COMPLICATING AURAL AFFECTIONS. 

CHAPTER XL. 

PAGES 

Aural Affections complicating the Acute Infectious 

Diseases 59 1 — 593 

Affection of perceptive apparatus — Involvement of conducting mech- 
anism — Character determined by degree of infection — Portions of 
tympanum involved — Extension to other regions. 



CHAPTER XLI. 

Aural Affections dependent upon Chronic Visceral 

Conditions 594-601 

Symptoms due chiefly to circulatory changes. Nephritis. Effect 
due to venous obstruction — Arterial sclerosis and impoverished 
quality of blood — Tympanic effusion— Extravasations — Labyrin- 
thine haemorrhage — Haemorrhage into nerve sheath. Metastasis. 
Embolism of labyrinthine vessels from remote suppurative process 
— Infection of middle ear. Tuberculosis. Tympanic involve- 
ment — Absence of pain — Multiple perforation — Constitutional 
treatment — Effect of tympanic process upon general condition. 
Leucaemia. Extravasation info labyrinth — Deposit of new tissue — 
Sudden appearance of symptoms — Diagnostic data. Diabetes. 
Frequency of inflammation in external meatus — As predisposing 
cause of middle-ear suppuration — Extravasations in labyrinth, nerve 
trunk, or centres. Gout and Rheumatism. Cutaneous manifes- 
tations in canal — Arthritic inflammation in middle ear — Changes in 
the blood vessels and the results. Medicinal Substances. Qui- 
nine — Effect on middle ear and labyrinth — Salicin and salicylic 
acid — Conditions contraindicating their administration — Tobacco — 
Effect upon higher centres. 



CHAPTER XLII. 

Disturbances of Audition dependent upon Functional 

Nervous Disorders . . . . . . : 602-607 

Unimportant physical changes as a cause of manifestations in a par- 
ticular region — Perversion or impairment of function with no evi- 
dent lesion. Neurasthenia. "Auditory strain" — Psychologi- 
cal effect — Character of impairment of hearing — General sensory 
paraesthesiae — Diagnosis — Physical examination often negative — 
Functional examination — Perception of high and low notes — Re- 
duction of bone conduction — Variable results obtained by succes- 
sive tests — Recognition of general neurotic condition — Hyperacusis 
— Auditory fatigue — Prognosis — Influence of organic changes in 
ear — Influence of general neurosis — Treatment — Strychnine — Bro- 
mides — Rest — Change of habit of life. Hysteria. Degree of 
impairment — Sudden appearance — Subsequent course — Associated 
hysterical paralyses — Transference — Absence of subjective noises — 
Diagnosis — Sudden onset — Absence of physical changes — Cutaneous 
anaesthesia — Functional examination — Contraction of range of au- 
dition — Upper tone limit most affected — Alternate variations in 
upper limit — Contraction of field of vision — Prognosis — Treatment 
— Attention to general neurosis— Hypnotic treatment. 

B 



xv i CONTENTS. 



CHAPTER XLIII. 

PAGES 

Reflex Aural Disturbances 608-613 

Vaso-motor changes — Trophic disturbances. External Meatus. 
Reflex inflammation — Cutaneous hyperesthesia — Haemorrhage. 

MlDDLE-EAR. Reflex otitis media — Otalgia — Angioneurotic oedema 
of mastoid. PERCEPTIVE Mechaxism. Paresthesia — Influence of 
visceral disorders — Interference with static function — Irregularity 
and transitory character of symptoms — Absence of local cause — 
Presence of remote lesion — Effect of one ear upon opposite organ — 
Physiological interdependence — Pathological correlation — Value of 
Electrical hyperesthesia in diagnosis — Prognosis — Duration of reflex 
symptoms — Nature of exciting cause — Treatment — Early adminis- 
tration of bromides — Removal of exciting cause — Antispasmodics — 
Opium contraindicated — Tonic treatment. 

CHAPTER XLIV. 

Deaf-mutism 614-618 

Definition — Varieties — ^Etiology. Congenital Form. Heredity 
— Consanguinity — Nationality — Social condition — Defective mental 
development — Specific disease — Causes operative during intra- 
uterine life. Acquired Form. Traumatism — Infectious diseases 
— Intracranial disease — Middle-ear inflammation — Adenoid vegeta- 
tions and the resultant tympanic condition — Cause of mutism in 
acquired form — Pathology — Congenital malformation of conducting 
or perceptive mechanism — Obstructive lesions of canal or tym- 
panum from a pathological process — Pathological conditions in the 
perceptive mechanism — Secondary atrophic changes — Symptoma- 
tology — Mutism in young children — In older children auditory im- 
pairment first noticed — Diagnosis — Difficulties in very young chil- 
dren — Importance of complete history — Importance of thorough 
functional examination with a series of musical tones — Prognosis — 
Congenital cases — Acquired cases — Possible errors — Treatment — 
Elimination of possible causes present — Removal of adenoid vege- 
tations — Internal medication — Necessity of early diagnosis — Early 
systematic instruction in cases not amenable to treatment. 

DISEASES OF THE NOSE AND NASO-PHARYNX. 

Classification of pathological conditions — Manner in which various 
local lesions affect sense of hearing. 

CHAPTER XLV. 

Hypertrophic Rhinitis.— Deformities of the Nasal Sep- 
tum 620-625 

Hypertrophic Rhinitis. Nature of tissue changes — Resultant 
conditions — Symptoms referable to upper air passages — Aural symp- 
toms — Referable to middle ear — Influence upon labyrinth — Relief 
of labyrinthine symptoms from intranasal treatment — Speculum ex- 
amination — Evidences of hypertrophy — Changes following the use 
of cocaine — Effect of treatment — Technique of local application — 
Surgical treatment. Deformities of the Nasal Septum. Method 
of removal with saw — Preparation of instruments — Dressing — Use 
of galvano-cautery. 

CHAPTER XLVI. 
Atrophic Rhinitis 626-628 

Pathological changes in membrane — Conditions resulting from the 
atrophic process — Insignificance of aural symptoms — Relation be- 



CONTENTS. xvii 

PAGES 

tween aural and nasal conditions — Treatment — Irrigation — Precau- 
tions in using nasal douche — Results of intranasal treatment upon 
the aural symptoms — Sprays — Local stimulation. 

CHAPTER XLVII. 
Adenoid Vegetations 629-632 

Importance of condition — Diathetic nature of affection — Symptoms 
referable to upper air tract — Aural symptoms — Otalgia — Discharge 
— Impairment of function — " Inattention " as a symptom — Condi- 
tion of oro-pharynx — Posterior rhinoscopy — Recognition by anterior 
rhinoscopy — Digital exploration — Technique of removal with for- 
ceps and curette — Possible sequelae to operation — Enlarged faucial 
tonsils — Effect upon audition — Methods of removal in children and 
adults. 

CHAPTER XLVIII. 
Naso-pharyngeal Catarrh 633-634 

Atrophic nature of process — Symptoms referable to vault of phar- 
ynx — Changes in ear concomitant rather than resultant — Aggrava- 
tion of aural condition by changes in naso-pharynx — Effect upon 
audition of treatment of naso-pharynx — Topical applications in 
acute conditions — Topical applications in chronic conditions. 



LIST OF ILLUSTRATIONS. 



COLORED PLATES. 

PLATE 

I.— The Arterial Supply of the Conducting Apparatus 
II. — The Venous Supply of the Conducting Apparatus 

III.— The Vascular Supply of the Cochlea 

IV. — The Auditory Nerve .... 
V. — The Membrana Tympani (i-6) 

VI.— The Membrana Tympani (7-12) . 

VII. — The Mastoid Operation 
VIII. — Operations for Intracranial Complications 



FACING 
PAGE 

29 
30 

44 

45 

296 

296 

5i5 
527 



ILLUSTRATIONS IN THE TEXT. 

FIGURE PAGE 

i. The cartilaginous framework of the auricle ..... 4 

2. The auricle ........... 5 

3. The cartilaginous meatus 6 

4. The incisures of Santorini . . . . . . . . .7 

5. The development of the temporal bone ...... 8 

6. Temporal bone of infant 9 

7. The adult temporal bone ......... 10 

8. The external meatus and membrana tympani of a child at birth . 10 

9. External meatus, membrana tympani, and middle ear from a child five 

years old . . . . . . . . . . .11 

10. Sagittal section through external auditory meatus, membrana tympani, 

and middle ear of an adult 11 

11. The internal tympanic wall . . . . . . . .12 

12. The internal tympanic wall and the vault of the tympanum, with ossi- 

cles in situ 14 

13. The ossicles and the annulus tympanicus . . . . . 15 

14. The malleus, incus, and stapes in various positions . . . .16 

15. The tympanum from above 18 

16. Section through mastoid, tympanum, and Eustachian tube . 19 

17. Transverse section of Eustachian tube 20 

18. The pockets of the membrana tympani ...... 24 

19. The malleo-incudal articulation covered by the superior malleo-incudal 

fold 24 

20. The nerves of the conducting mechanism and their anastomotic 

branches . 32 

(xix) 



XX 



LIST OF ILLUSTRATIONS. 



41. 

42. 

43- 
44. 

45- 
46. 

47- 



49 



50. 

52. 
53- 
54- 
55- 
56. 

57. 
58. 

59- 
60. 



FIGl'RK 

21. The nerve distribution within the tympanum 

22. The bony labyrinth 

23. The membranous labyrinth 

24. Vertical section of the membranous cochlea 

25. Pen drawing from adult specimen, showing result of drawing auricle 

upward and backward .... 

26. Drawing from specimen at birth 

27. Drawing from specimen from child aged five years 

28. Author's portable illuminating apparatus . 

29. Hand mirror 

30. Reflecting mirror adapted for hand or head 

31. Head mirror with nasal support 

32. Head mirror 

33. Electric lamp worn upon the forehead 

34. Politzer's hard-rubber aural speculum 

35. Wilde's aural speculum 

36. Gruber's aural speculum 

37. Toynbee's aural specula ..... 

38. The ocular inspection of the membrana tympani 

39. The normal membrana tympani 

40. Middle-ear probe 

Cotton holder ....... 

Siegle's pneumatic speculum .... 

Auscultation tube ...... 

Politzer's air bag 

The Eustachian catheter ..... 

Introduction of the Eustachian catheter (first step) 

Introduction of the Eustachian catheter (second step) 

Introduction of the Eustachian catheter (the instrument in the mouth 

of the tube) ..... 
Vertical section through nasal chambers and pharyngeal vault of 

adult 

The same in a child of five years 

Section through nasal passages and naso-pharynx in an infant 

Noyes's Eustachian catheter 



Pomeroy's faucial catheter 

Bosworth's nasal speculum 

Bosworth's tongue depressor 

Folding tongue depressor .... 

Tiirck's tongue depressor .... 

Rhinoscopic mirror ..... 

Politzer's acoumeter 

Urbantschitsch's electric acoumeter . 

61. The author's tuning fork .... 

62. The author's modification of the Galton whistle 

63. Blake's tuning fork 

64. Hartmann's series of tuning forks 

65. Anomalous division of the antihelix . 

66. Microtia 



LIST OF ILLUSTRATIONS. xxi 

FIGURE PAGE 

67. Auricular appendage . . . . . . . . .179 

68. Fistula congenita auris . . . . . . . . . 179 

69. Polyotia 180 

70. Aural ice bag 185 

71. Deformity following perichondritis 200 

72. Othematoma ........... 202 

73. Soft fibroma filling the concha 206 

74. Atheroma 208 

75. Sebaceous tumor of the lobule 208 

76. Cystoma of auricle 211 

77. Otitis externa acuta circumscripta 222 

78. Otitis externa acuta of deep portion of meatus 223 

79. Bacon's scarificator .......... 227 

80. Author's artificial leech 228 

81. The Leiter coil 229 

82. Hard-rubber ear syringe 234 

83. Development of a fungus - . . . 241 

84. Microscopic characteristics of otomycosis 242 

85. Otomycosis 246 

86. Aspergillus flavus 247 

87. Appearance in infancy due to escape of fluid from tympanum through 

Rivinian fissure 249 

88. Acute diffuse external otitis . . . . . . ... 257 

89. Crust on supero-posterior wall of canal covering perforation in mem- 

brana tympani 272 

90. Method of removing cerumen with the curette 276 

91. Linear rupture of the membrana tympani ..... 293 

92. Retraction of the membrana tympani 303 

93. Author's bougie catheter for the Eustachian tube .... 309 

94. Author's middle-ear vaporizer . . . . . . . . 311 

95. Moderate retraction of membrana tympani ; incudo-stapedial articu- 

lation visible 317 

96. Bulging of the posterior segment of the membrana tympani . . 317 

97. Method of incising the membrana tympani . . . . .321 

98. Moderate bulging of the entire membrana tympani .... 328 

99. Blake's middle-ear syringe ........ 334 

100. Acute purulent otitis media ; bulging of membrana flaccida . . 341 

101. Acute purulent otitis media; fluid confined in the pockets of the 

membrane 342 

102. Chronic catarrhal otitis media ; rotation of malleus upon its long 

axis 358 

103. Chronic catarrhal otitis media ; supernumerary posterior fold . . 359 

104. Chronic catarrhal otitis media ; moderately retracted membrane . 377 

105. Delstanche's masseur . . . . . . . . . 381 

106. Chronic purulent otitis media ; extensive destruction of membrana 

vibrans 395 

107. Chronic purulent otitis media ; exuberant granulations in tympanum. 395 

108. Chronic purulent otitis media ; margin of perforation partially ad- 

herent 395 



xxii LIST OF ILLUSTRATIONS. 

FIGURE PAGE 

109. Chronic purulent otitis media ; perforation in membrana flaccicla . 396 
no. Chronic purulent otitis media ; displacement of ossicles . . . 396 
in. Chronic puruknt otitis media; small perforation in posterior quad- 
rant 396 

112. Removal of an aural polyp with the snare ..... 406 

113. Removal of an aural polyp with the sharp curette .... 407 

114. Irrigation of the tympanic vault ....... 410 

115. Inspissated secretion covering a small perforation in the membrane. 424 

116. The pneumatic mastoid 432 

117. The diploic mastoid 433 

118. Horizontal section through mastoid, showing the position of the sig- 

moid groove 434 

119. Section through mastoid, showing the relative position of the lateral 

sinus and the antrum 434 

120. Section through mastoid, showing the sinus in an anomalous posi- 

tion 435 

121. Anomalous development of the temporal ridge .... 437 

122. The tympanic vault and mastoid antrum at birth .... 438 

123. Instruments for middle-ear operations ...... 466 

124. Author's head and shoulder rest 469 

125. Lance-shaped myringotome 470 

126. Method of incising the membrana flaccida for depletion . . . 472 

127. Exploratory myringotomy 473 

128. Author's scissors for middle-ear operations 475 

129. Hartmann's tenotome 477 

130. Tenotomy of the tensor tympani 478 

131. Tenotomy of the tensor tympani 478 

132. Tenotomy of the tensor tympani 479 

133. Division of tympanic adhesions 481 

134. Division of adhesions behind the stapes 483 

135. Disarticulation at the incudo-stapedial joint 483 

136. Exposure of the incudo-stapedial joint 487 

137. McKay's ear forceps 489 

138. Incus hook in position 49 1 

139. Author's chisel forceps 493 

140. Incus partially destroyed by caries 507 

141. Scalpel for incision of the soft parts in the mastoid operation . .515 

142. Thumb forceps . . . . . . . . • .516 

143. Scissors curved on the flat 5*6 

144. Sharp retractor 5 10 " 

145. Periosteum elevator 5 J 6 

146. Hartmann's periosteum elevators S l 7 

147. Rongeur forceps S l 7 

148. Sharp spoon S l 7 

149. Schwartze's chisels . . . . . . • . • .518 

150. The vault of the tympanum as seen after removal of the outer wall . 524 

151. The topographical relations between the cranial contents and the 

outer surface of the skull 5 2 & 

152. Leucsemic infiltration of the cochlea ...... 598 



SECTION I. 

THE ANATOMY AND PHYSIOLOGY 
OF THE EAR. 



THE ANATOMY AND 
PHYSIOLOGY OF THE EAR. 



CHAPTER I. 

THE ANATOMY OF THE EAR. 

The auditory apparatus, through the agency of which 
certain forms of motion are interpreted as sound, may best 
be considered as consisting of two parts — a conducting mech- 
anism and a receptive mechanism. The conducting mech- 
anism collects the vibrations of the sounding body and trans- 
mits them to the receptive mechanism, through which this 
motion is recognized as sound. 

This division of the subject affords a much clearer view of 
the function of the various parts concerned in audition, in 
health and in disease, than that obtained by adhering strictly 
to the anatomical divisions of the external, middle and inter- 
nal ear. 

The conducting apparatus includes the external and mid- 
dle ear. The middle ear is simply the more delicate and 
complicated portion of the transmitting mechanism, and 
therefore is more carefully protected from injury, both by its 
situation at a distance from the external surface of the body 
and by the presence of the membrana tympani. It is probable 
that the function of this structure is almost entirely protective, 
and that it plays but an unimportant part in the transmission 
of sound vibrations. That portion of the conducting tract 
which it separates from the outer world communicates with 
the surface of the body by means of the Eustachian tube ; it 
seems wiser, therefore, to consider the external and middle 
ear and Eustachian tube together, rather than as individually 
distinct, since they perform a single function. 

(3) 



THE ANATOMY AND PHYSIOLOGY OF THE EAR. 



The second portion, the receptive mechanism, includes not 
only the internal ear, or labyrinth, but, in addition, the trunk 
of the auditory nerve, its central and cortical nuclei and fibres 
of association and projection. The labyrinth, then, represents 
but a small portion of the receptive mechanism, constituting 
the specialized end organ of the auditory nerve, through 
which vibrations in the labyrinthine fluid produce specific 
impressions upon the cerebrum. It can be seen at once how 
much more comprehensive the range of aural pathology be- 
comes when this view is taken, than when anatomical divisions 
alone are followed. 

I. The Conducting Apparatus. 

Under this head we include the auricle and the cartilag- 
inous meatus, the bony external auditory meatus, the mem- 
brana tympani, the tympanum, and the Eustachian tube. 

The auricle and the cartilaginous meatus together form an 
irregularly funnel-shaped device for transmitting aerial vibra- 
tions to the deeper parts, the auricle constituting the wide 
portion of the funnel, the cartilaginous meatus the tubular 
portion. 

The Auricle. — The auricle consists of a thin plate of fibro- 
cartilage, oval in outline, attached to the side of the skull 

at an acute angle 
with the median an- 
teroposterior verti- 
cal plane of the body. 
Its posterior surface 
is convexand smooth, 
while the concave 
anterior surface pre- 
sents certain irreg- 
ularities which merit 
special description. 
The unattached bor- 
der of this oval car- 
tilaginous plate is 
folded forward upon 
itself to such an ex- 
tent that the free 
margin appears upon the anterior or external surface, form- 
ing the helix. Above, the helix does not terminate at the 




Fig. i. — The cartilaginous framework of the auricle 
(After Politzer.) 



THE AURICLE. 



5 




Helix. 



Antitragus. 



Fig. 2. — The auricle. 



supero-anterior attachment of the auricle, but is continued 
backward and slightly downward from this point, as a promi- 
nent ridge, the crista helicis, which forms the superior 
boundary of the cartilaginous meatus. 

At the base of the crest a minute spur of cartilage ex- 
tends downward, constituting the spina helicis. Followed in 
the opposite direction, the 
helix is seen to terminate 
in an elongated cartilagi- 
nous process, the processus 
caudatus ; the spine of the 
helix and the caudate pro- 
cess can rarely be recog- 
nized on the living subject, 
but are discernible upon 
the cadaver after carefully 
removing the integument 
covering the auricle (Fig. 

The groove beneath the 
helix is called the fossa of 
the helix, or scaphoid fossa. Immediately in front of this 
fossa is a broad convex ridge running parallel to the helix 
called the antihelix, dividing above into two branches — the 
crura helicis or the crura furcata. These crura inclose be- 
tween them the fossa of the antihelix. The antihelix termi- 
nates below in a cartilaginous prominence — the antitragus. 
Immediately in front of the antihelix and extending down- 
ward as far as the antitragus is a deep cavity called the con- 
cha; this depression is partially divided by the spine of the 
helix into two unequal parts, of which the superior is the 
smaller and lies between the spine of the helix and the ante- 
rior crus of the antihelix, while the larger division lies in 
front of the antihelix and above the antitragus. As already 
stated, the superior margin of the cartilaginous meatus is 
formed by the spine of the helix ; its posterior and inferior 
margins constitute the anterior and inferior boundaries of the 
concha. In front of the entrance to the meatus, slightly cov- 
ering it and continuous with its anterior wall, there is a 
prominent cartilaginous tubercle, somewhat pyramidal in 
shape, called the tragus. This is separated from the anti- 
tragus by a deep broad notch, the fissura intertragica. The 



THE ANATOMY AND PHYSIOLOGY OF THE EAR. 



tragus is not completely separated from the antitragus by this 
fissure, the bases of the two processes becoming continuous at 
the junction of the anterior and inferior walls of the cartilag- 
inous meatus. Above, the tragus is completely separated 
from the spine and crest of the helix, the intervening space 
being filled with dense connective tissue. 

From the preceding description, it will be seen that while 
the contour of the cartilaginous margin of the auricle above, 
anteriorly and posteriorly, is fairly regular, its inferior margin 
from the processus caudatus of the helix to the fissura inter- 
tragica presents numerous irregularities of outline. These 
indentations are filled up by a mass of adipose connective tis- 
sue which, extending downward for a variable distance, gives 
a regular outline to the pinna. To this process the name of 
lobule is given. The walls of the irregular, funnel-shaped 
auricle, therefore, gradually converge to form the cartilagi- 
nous meatus. 

The Cartilaginous Meatus. — The lumen of this canal is 
oval in shape when viewed in cross section, the long axis of 

the ellipse being inclined at an 
angle of about sixty degrees to 
the horizontal plane. The in- 
ner extremity of this canal is 
attached by means of firm 
bands of connective tissue to 
the margin of the bony meatus. 
The cartilaginous framework 
of the canal is wanting above 
and posteriorly, this deficiency 
becoming greater as the canal 
extends inward, until at its ter- 
mination the inferior wall only 
is cartilaginous, being pro- 
longed for a short distance 
along the floor of the bony 
meatus as a tongue-shaped cartilaginous process, known as 
the processus triangularis * (Fig. 3). 

The wall of the canal is completed by firm connective tis- 
sue, which fills up the hiatus in its cartilaginous portion. This 
fibrous tissue is continuous with the periosteum of the corre- 




Fig. 3. — The cartilaginous meatus. 
(Politzer). c, Processus triangu- 
laris ; i, i, Incisures of Santorini. 



* Politzer, Zergliederung des menschlichen Gehororgans, 1889, p. 57. 



THE EXTERNAL MEATUS. 




sponding portion of the bony canal. The anterior wall of the 
cartilaginous meatus presents two vertical fissures (Figs. 3 
and 4) which pass completely through its substance. The 
spaces thus left are filled with connective tissue, with an 
occasional admixture of striped muscular fibres. These fis- 
sures are called the incisures of Santorini. The more extensive 
of the two is situated at the base of the tragus ; the second is 
farther inward, while a third is occasionally met with beyond 
this. These fissures ren- 
der the cartilaginous 
meatus more freely mov- 
able, and are important 
clinically, for through 
them deep abscesses of 
the parotid gland, dis- 
charging spontaneously, 
rupture into the canal 
on account of the weak- 
ness of the walls at this 
point. From a surgical 
standpoint these dehis- 
cences are important, 
since they enable us to 
turn the auricle and fibrocartilaginous canal forward on the 
cheek, after separation of the posterior, inferior, and superior 
attachments. 

The Bony Canal. — In order properly to understand the 
osseous meatus, it will be necessary to consider somewhat in 
detail the development of the temporal bone. This portion 
of the skull develops from four centers : the squamous, the 
petro-mastoid, the auditory or tympanic, and the stylomas- 
toid. This last center of ossification does not concern us, but 
the other three are of importance, as they are all integral parts 
of the auditory apparatus, and, with the exception of the pe- 
trous portion, all enter into the formation of the external 
meatus. The manner in which these various portion unite 
to form the temporal bone is shown in Fig. 5, which is some- 
what diagrammatic. 

The osseous meatus does not exist at birth, its place being 
supplied by a canal of fibrous tissue. Reference to Figs. 8, 
9, and 10, drawn from specimens prepared by the author, 
renders this clear. At its inner extremity this terminates in 



Fig. 4. 



-a, a, The incisures of Santorini. 
(Urbantschitsch.) 



s 



THE ANATOMY AND PHYSIOLOGY OF THE EAR. 



the auditory process or the tympanic ring. The auditory 
process (Figs. 5 [2] and 13 fill]) consist of a thin osseous strip 
bent in the form of an oval, the curvilinear outline being 
wanting for about an eighth of its circumference at the broader 




Fig. 5. — The development of the temporal bone. I, The squamous portion ; 2, 
The tympanic ring ; 3, The petro-mastoid portion. The upper figure illustrates 
the union of the three portions. (Modified from Gray.) 



pole. The concave margin of this bony ring is grooved for 
the insertion of the membrana tympani, and is named the 
sulcus tympanicus, while the ring itself is called the annulus 
tympanicus. The free extremity of the posterior limb of the 
annulus is called the spina tympanica posterior or spina tym- 
panica minor. Just below the extremity of the anterior limb 
a bony spine projects backward, the spina tympanica major. 
The spina tympanica anterior is directed forward, and con- 
sists of a small bony tubercle lying just beneath the larger 
tympanic spine. 



THE BONY MEATUS. 



The squamous portion of the temporal bone develops 
from a single center. Early in fcetal life it consists of a flat 
osseous scale, presenting a ridge upon its outer surface, 
which afterward becomes the zygomatic process. Below the 
root of this process is a shallow excavation, the glenoid fossa. 
Behind this depression the bony plate divides into two la- 
mellae, the inner of which is directed almost horizontally 
inward and forms subsequently the roof of the tympanum 
and of the mastoid antrum. The external lamella passes 
downward and somewhat inward and exhibits a deep 
notch upon its inferior border. The annulus tympanicus 
joins the external plate of the squama by the union of the 
free extremities of its anterior and posterior limbs to the 
corresponding angles of the notch above described. The 
curvilinear outline of the ring is 
completed by the notched inferior 
border of the external plate of the 
squamous portion of the temporal 
bone. This is shown in Fig. 6. 
The circlet thus completed gives 
attachment to the inner extremity 
of the fibrous canal, which occupies 
the position of the future bony 
meatus. As development pro- 
gresses, the fibrous canal is replaced 
by osseous tissue. The annulus 
tympanicus is converted into a 
bony groove by ossification out- 
ward, and, as will be seen by consulting Figs. 8, 9, and 10, 
the process effects simply the separation of the superior 
and inferior walls, which at birth are in contact. This gutter 
forms the anterior, inferior, and posterior walls of the bony 
meatus, the superior wall being formed by that portion of 
the temporal bone which completes the osseous outline of 
the annulus tympanicus. 

In the adult temporal bone (Fig. 7) the deep groove formed 
by the outward growth of the annulus tympanicus is called 
the auditory process. It is separated in front from the squa- 
mous portion of the temporal bone by a narrow fissure called 
the Glaserian fissure ; posteriorly the auditory process enters 
into the formation of the mastoid squamous suture, its postero- 
superior termination constituting the spinum supra-meatum. 




Fig. 6. — Temporal bone of in- 
fant, natural size. (Author's 
collection. 



IO 



THE ANATOMY AND PHYSIOLOGY OF THE EAR. 



The external plate of the squama, which completes the out- 
line of the bony meatus, during development grows almost 




Fig. 7. — The adult temporal bone, natural 
size. (Author's collection.) 



directly outward in a horizontal direction, and nearly at right 
angles to that portion of the temporal bone lying above the 

zygomatic process. As previously 
stated, the fibrous tissue which oc- 
cupies the place of the bonv meatus 
at birth is gradually replaced by 
bone, and this part of the meatus, 
which at first was movable, be- 
r / J| mL comes bony and rigid. As a re- 

sult, the angle between the mem- 
brana tympani and the superior 
wall of the canal becomes appar- 
ently more acute as development 
advances. The actual angle of in- 
clination of the membrane with the 
horizontal plane probably does not 
change to any degree after birth. 
The line of demarcation between 
Fig. 8.— The external meatus and it and the superior wall is more 

membrana tympani of a child at ., , A . , , , •-, , 

birth, natural size. The meatus easily made out in older children 

has been split, and the superior an( J adults, On account of the 
and inferior walls have been . 

held apart. (Author's specimen.) change taking place in the meatus. 




THE BONY MEATUS. 



I I 



At birth the superior and inferior walls are in contact and 
must be separated in order to inspect the membrana tympani, 
as the specimen from which Fig. 8 was drawn shows. In 
this specimen the anterior wall of the canal was cut through, 
from just in front of the tragus to the membrana tympani, 
and the walls separated so that the parts could be seen and 
drawn. 

When we compare this drawing with Figs. 9 and 10, repre- 
senting the same region in childhood and adult life, we see 
at once that the formation of the bony canal may be said to 
have effected this separation and made it permanent, simply 
by the deposit of bony tissue, rendering the fibrous tube rigid. 





Fig. 9. — External meatus, membrana tym- 
pani, and middle ear from a child five 
years of age, natural size. (Author's 
specimen.) 



Fig. 10. — Sagittal section through ex- 
ternal auditory meatus, membrana 
tympani, and middle ear of an adult, 
natural size. (Author's collection.) 



The third portion of the temporal bone, the petro-mastoid 
part, consists of an oblique triangular osseous pyramid, the 
apex of which is directed forward and inward, while its base 
fills up the gap between the free margin of the squamous 
plate of the temporal bone and the posterior crus of the 
annulus tympanicus, at the same time extending forward, so 
that the anterior portion of this surface lies opposite the tym- 
panic ring. 

The line of union of the mastoid portion to the external 
squamous plate is the mastoid squamous suture. Looking at 
the cranial surface, we find that the petrous portion unites 



12 THE ANATOMY AND PHYSIOLOGY OF THE EAR. 

with the inner plate of the squama, forming the petrosqua- 
mous suture. 

It is clear from the foregoing description that the base of 
the pyramid is made up of the outer surface of the mastoid 
and of that portion of the petrous bone lying below the petro- 
squamous suture and opposite the tympanic ring. This last 
region corresponds to the inner wall of the tympanic cavity, 
or the fundus of the external auditory meatus, the membrana 
tympani having been removed. 

The Tympanic Cavity. — The tympanic cavity is a bony 
chamber the inner wall of which is formed by the external 
surface of the petrous portion of the temporal bone. This 
wall (Fig. n) presents for inspection a rounded eminence, 

called the promontory, covering 
the first turn of the cochlea. Be- 
hind, and somewhat beneath the 
promontory, there is a niche called 
stapes. W>Lj /i 1 ^"^^"^ the niche of the round window. 




Round M^/\^y^^~^n into which the fenestra rotunda 

opens. This niche looks almost 
directly backward, and even when 
the parts are most favorably dis- 
posed for inspection, but a very 

FlG wLnr[Au e t ho n r 's e Tp a e I cir„ P r iC limited area of the depression is 

visible. iVbove, in the upper and 
posterior portion of the inner wall, is an oval fossa, the pelvis 
ovalis, at the bottom of which is the oval window. In Fig. 
n the stapes is in position, and fills the pelvis ovalis. The 
posterior wall of the pelvis ovalis is abrupt, while its anterior 
wall slopes gradually forward until it merges into the sur- 
face of the promontory. The inferior wall is longer and 
more precipitous that the superior wall. The lumen of the 
fenestra ovalis looks outward and downward. At birth the 
pelvis ovalis is separated from the niche of the round win- 
dow by a deep fossa, the sinus tympanicus (seen in Fig. 6), 
which usually disappears completely in adult life. Above 
the oval window there is a distinct bony arch formed by the 
encroachment of the outer wall of the aqueductus Fallopii 
upon the tympanic cavity. The facial nerve passes through 
this canal. Directly above this bony ridge there is another 
and smaller bony crest, caused by the projection of the hori- 
zontal semicircular canal outward into the cavity of the 



THE TYMPANIC CAVITY. ^ 

middle ear. The outer wall of the aqueductus Fallopii is 
occasionally incomplete, the facial nerve being then exposed 
in its passage through the tympanum. Behind the pelvis 
ovalis, at the juncture of the inner and posterior walls of the 
tympanum, there is a small bony pyramid, through the apex 
of which the tendon of the stapedius muscle passes. The 
plane of the inner wall of the tympanic cavity lies more 
nearly in the median antero-posterior vertical plane of the 
body than does that of the tympanic ring; hence the tym- 
panic cavity is broader above and posteriorly, than below 
and anteriorly. In front of the promontory the inner wall is 
smooth and gradually merges into the tympanic opening of 
the Eustachian tube. 

The anterior wall of the tympanum presents at about its 
centre, the tympanic orifice of the Eustachian canal. Above 
this, and separated from it by a thin bony plate, the proces- 
sus cochleariformis, is the canal for the tendon of the tensor 
tympani muscle. The anterior wall is separated from the in- 
ternal carotid artery as it passes through the carotid canal 
by a thin, bony plate. The osseous floor of the cavity lies at 
a considerable distance below the lower margin of the tym- 
panic ring. It is sometimes formed of fairly compact bone, 
but quite frequently it is cancellous ; it is in relation with the 
jugular fossa, which lodges the bulb of the internal jugular 
vein, and may present dehiscences, exposing the bulb to trau- 
matism by instruments introduced into the meatus. 

The posterior wall presents, at its junction with the inter- 
nal wall, the pyramid, through the apex of which the tendon 
of the stapedius muscle passes. The opening into the mastoid 
antrum lies directly above this process. The external wall of 
the tympanum is formed chiefly by the membrana tympani 
(a structure which will be described presently), by the inner 
surface of the tympanic ring, and above by the inner margin 
of the external plate of the squama and by the angle formed 
by the separation of the inner and outer plates. It becomes 
evident, therefore, that the tympanic cavity is prolonged up- 
ward for a considerable distance above the plane of the supe- 
rior wall of the meatus. This portion of the cavity is the 
epitympanic space or recess, or the vault of the tympanum. 
The portion lying below this plane is called the atrium. 

The Vault of the Tympanum (Fig. 12). — The epitympanic 
space is somewhat pyramidal in shape, the apex lying at the 




I 4 THE ANATOMY AND PHYSIOLOGY OF THE EAR. 

angle between the two plates of the squama. These plates, 
with the adjoining- portions of the petrous bone and the petro- 
squamous suture, complete two 
osseous faces of the pyramid ; 
the remaining surface and the 
base are partly wanting, being 
represented by the openings 
leading into the mastoid antrum 
posteriorly, and into the tym- 
k >r^ panic cavity below. When the 
parts are in their normal posi- 
tion this lower surface is par- 

.blG 12. — 1 he internal tympanic wall r 

and the vault of the tympanum, tially completed by the ossicula, 

thor'scoikTtion S ) in POSiti ° n " (AU " their ligaments, and the redu- 
plications of the mucous lining 
of the tympanum, which shut off the upper portion of the 
cavity more or less perfectly from the lower part. 

The Ossicles (Figs. 13 and 14). — The ossicular chain is 
lodged within the tympanum, and serves to transmit and 
modify sound vibrations. It constitutes, in reality, a lever 
through which the impulses transmitted to the labyrinthine 
fluid are increased in intensity, but diminished in amplitude. 

The ossicles are three in number: the malleus, incus, and 
stapes. According to Rathke* and Urbantschitsch,f the 
malleus and incus are developed from one nucleus, and sub- 
sequently become separate bones, intimately connected at 
their articular surfaces, while the stapes develops from a dis- 
tinct centre of its own. 

Gradenigo { believes that the foot plate of the stapes 
springs from the capsule of the labyrinth, while the remain- 
der develops from the second visceral arch, the two portions 
subsequently uniting. 

The Malleus. — The malleus is the largest ossicle of the 
series, and consists of a head and shaft joined to each other at 
an obtuse angle by a constricted portion called the neck. The 
shaft or long process is prismatic on cross section, and tapers 
gradually from just below the neck of the ossicle to the tip, 
which is sometimes bent slightly forward in the form of a hook. 



* Kiemenapp. und Zungenb., 1832, p. 122. 
f Lehrb. der Ohrenheilk., Wien, 1890, p. 229. 
\ Med. Jahrbuch, Wien, 1887. 



THE OSSICLES. 



15 



At the junction of the shaft with the neck there is a prominent 
bony tubercle called the short process of the malleus, which 
is directed forward and outward. The prismatic shaft pre- 
sents an external border for attachment to the membrana 
tympani, an internal border directed toward the labyrinthine 
wall, and somewhat broad anterior and posterior surfaces. It 
is evident that any rotation of the malleus upon the long axis 




Fig. 13. — The ossicles and the annulus tympanicus. I, Ossicular chain of left ear. 

1, Malleus ; 2, Incus ; 3, Stapes. II, Ossiculus chain of right ear. I, Malleus ; 

2, Processus folianus ; 3, Manubrium ; 4, Long process of incus ; 5, Short process 
of incus ; 6, Stapes. Ill, Annulus tympanicus. I, Anterior tubercle ; 2, Pos- 
terior tubercle. (Riidinger : Blake's translation.) 



of the manubrium will alter the apparent breadth of the shaft 
as viewed through the meatus, according as the degree of 
rotation brings the broad anterior or posterior surface into 
view, or the sharp edge which marks the junction of these 
surfaces with the anterior border. Springing from the an- 



l6 THE ANATOMY AND PHYSIOLOGY OF THE EAR. 

terior surface just below the short process is a long-, delicate, 
bony spicule, the processus folianus or gracilis, which lies in 
the Glaserian fissure, and in adult life is frequently imbedded 
in the fibres of the anterior ligament. The external surface 
of the neck of the malleus is roughened for the attachment of 
the external ligament. The anterior surface of the neck and 




Fig. 14. — The malleus, incus, and stapes in various positions. (Rudinger : Blake's 

translation.) 

the adjoining portion of the head are deeply grooved for the 
insertion of the anterior ligament. The head is irregularly 
spherical in shape, the spherical contour being encroached 
upon posteriorly by the saddle-shaped surface for articulation 
with the incus, while anteriorly there is a groove for the at- 
tachment of the anterior ligament. 



THE OSSICLES. 



17 



The Incus. — The central ossicle of the chain consists of a 
body and two processes. The short or horizontal process — a 
continuation of the body — is conical in shape and extends 
backward, its tip resting in a little pit or fossa in the posterior 
tympanic wall, just below the entrance to the mastoid antrum. 
This depression is called the sella incudis. The body of the 
bone is flattened from before backward, the vertical diameter 
being about double the transverse. The anterior surface, 
forming the base of the cone, is saddle-shaped for articulation 
with the malleus. The long or descending ramus of the incus 
is a long, tapering bony shaft, extending downward from the 
antero-inferior angle of the body ; its lower extremity is bent 
inward so that the tip of the process is directed toward the 
internal tympanic wall. This free extremity is called the len- 
ticular process, and articulates with the head of the stapes. 
The lenticular process in fcetal life is represented by a sepa- 
rate bone, the os orbiculare. 

The Stapes. — The innermost ossicle of the series brings the 
conducting mechanism into immediate relation with the re- 
ceptive apparatus. As the name implies, it is stirrup-shaped, 
and consists of a small rounded head the external face of 
which is hollowed out for articulation with the lenticular pro- 
cess of the incus ; below the head is a constricted portion 
called the neck, from which the crura diverge. The posterior 
crus is the longer and more curved. The crura terminate in 
an oval or kidney-shaped plate of bone, the foot-plate of the 
stapes, which closes the oval window. The entire stapes lies 
almost wholly within the pelvis ovalis, hence when the mem- 
brana tympani is wanting it is well protected from traumatism 
from instruments introduced through the canal. The stapes 
lies obliquely in the oval niche, being nearer to the inferior 
and posterior walls of the fossa than to the anterior and supe- 
rior. Since the posterior wall of the niche is almost vertical, 
the corresponding stapedial crus lies close to it, and adhesions 
between this wall and the posterior limb of the ossicle are of 
frequent occurrence. 

The ossicular chain is suspended in the tympanic cavity 
by a series of ligaments which bind the individual members 
of the chain to each other and to the walls of the tympanum. 

Ligaments of the Malleus (Fig. 15). — These are four in 
number : the anterior, external, posterior, and superior or sus- 
pensory ligament. 
3 




18 THE ANATOMY AND PHYSIOLOGY OF THE EAR. 

llic anterior ligament is the strongest of these. It arises 
from the spina tympanica major and from the walls of the 
Glaserian fissure, some of the fibers traversing the length of 
the fissure and taking their origin from the spine of the sphe- 



External ligament. 



Anterior ligament. 



Stapes. 

Tendon of ten- 
sor tympani. 

Fig. 15. — The tympanum from above. (Author's specimen ) 

noid. From this extensive origin they pass outward, upward, 
and backward, and are inserted into the anterior surface of 
the neck of the malleus and into the depression found on the 
anterior surface of the head. They inclose the processus 
folianus of the malleus. 

The external ligament is somewhat fan-shaped. It springs 
from the external roughened surface of the neck of the ossicle, 
from which point the fibers diverge to be inserted into the 
free margin of the inner extremity of the superior w r all of that 
portion of the bony meatus formed by the external plate of the 
squama. The posterior fibres, according to Helmholtz, form 
a distinct band called the posterior ligament of the malleus.* 

This portion of the external ligament, together with the 
anterior ligament, forms the axis band of the hammer, since 
the axis of rotation of the ossicle is approximately a line drawn 
through the attachment of these two ligamentous structures. 

The superior ligament is a delicately rounded band of 
fibrous tissue running from the tegmen tympani downward 
to the head of the malleus. 

The Ligaments of the Incus. — The incus is bound to the 
tympanic wall by a single fibrous band, the posterior liga- 



* The Mechanism of the Ossicles. Translated by Buck and Smith, New York, 

1873. 



THE INTRATYMPANIC LIGAMENTS. 



19 



ment, which extends from the lateral aspects of the short 
process near its extremity to the posterior wall of the tym- 
panum. At its origin it is dense in structure, owing to the 
somewhat limited area from which it arises. From this point 
the fibres diverge rapidly and divide into two bundles to be 
inserted into a broad area on the posterior wall of the tym- 
panum. On account of this broad insertion it is sometimes 
called the fan-shaped ligament of the incus. The inferior sur- 
face of the short process lies in a shallow depression in the 
tympanic wall called the sella incudis, the opposing surfaces 
being covered with cartilage. 

The Ligaments of the Stapes. — The foot plate of the 
stapes is confined in the oval window by the stapedio-ves- 
tibular or annular ligament. The margins and vestibular sur- 
face of the foot plate and the periphery of the oval window 
are covered with hyaline cartilage, the annular ligament de- 
veloping from the perichondrium. 

Interossicular Ligaments. — The malleus and incus are 
bound together by a loose capsular ligament, the articular 
surfaces of the ossicles being covered with cartilage. The 
incudo-stapedial articulation is similar in character. 

The Eustachian Tube. — Having traced the bony and car- 
tilaginous framework of the conducting mechanism inward 



an n 




Fig. 16. — Section through mastoid, tympanum, and Eustachian tube. (Politzer.) 
W, W, Mastoid cells ; mt, Membrana tympani ; an, Antrum ; n, Vault of tym- 
panum ; it, Isthmus of tube ; te, Eustachian tube ; op, Pharyngeal orifice of 
tube. 



to the point where it joins the receptive portion of the audito- 
ry apparatus at the oval window, we have next to consider 
the characteristics of that passage by means of which certain 
delicate parts of this system can be protected by a fibrous 



20 Tlii: ANATOMY AND PHYSIOLOGY OF THE EAR. 

covering without interfering with the transmission of sound 
waxes. By means of the canal now to be described an equal 
atmospheric pressure is maintained upon either side of this 
protecting septum. This passage is the Eustachian tube. It 
is made up of two portions — the tympanic or bony, and the 
pharyngeal or cartilaginous portion — their point of junction 
being called the isthmus of the tube. The osseous segment 
is about half an inch in length, and, extending from a 
somewhat wide orifice just above the middle of the internal 
wall of the tympanum, narrows quickly as it passes down- 
ward, forward, and inward through the substance of the pe- 
trous portion of the temporal bone, until at the isthmus its 
diameter varies from one tw T enty-fifth to one twelfth of an 
inch. The canal is irregularly triangular in shape, the verti- 
cal diameter being double the transverse. This osseous tube 
is joined at the isthmus to the cartilaginous portion by fibrous 
tissue, the parts uniting at an obtuse angle, the opening of 
which is directed downward and forward. The pharyngeal 
portion measures about an inch in length, and at the isthmus 
its lumen corresponds to that of the osseous channel. As it 
extends downward into the pharynx, however, it grows wider, 
and at the pharyngeal orifice measures from one eighth to 
one fifth of an inch in diameter, the vertical diameter being 
greater than the transverse. This portion of the canal is 
fibrocartilaginous. The posterior wall 
is formed by a plate of cartilage, the 
upper border of which is bent first 
forward and then downward, so that 
a transverse section would be hook- 
shaped (see Fig. 17). The space in- 
closed by the, bending forward of the 
cartilage forms the superior portion of 
the lumen of the tube, the interval be- 
tween the free margin of the angular 
portion and the lower border of the 
.3Pllll cartilaginous plate being filled with 

Fig. 17.— Transverse sec- fibrous and muscular tissue, thus com- 

tion of Eustachian tube. i .. ,1 i n7 .1 r 

(After Zuckerkandi.) pletmg the canal. We see, therefore, 

that the posterior, superior, and a small 

portion of the anterior wall of the tube is cartilaginous, while 

the remainder of the anterior and entire inferior wall is 

fibrous, the passage being slitlike rather than circular on cross 




THE MEMBRANA TYMPANI. 21 

section, with the anterior and posterior walls in contact except 
at the upper part. The membranous tube is attached to the 
inner extremity of the bony canal, the posterior cartilaginous 
plate uniting with a prolongation of the corresponding bony 
wall. Beyond the isthmus the tube is suspended from the 
base of the cranium by fibrous bands passing to its superior 
wall, until it terminates in the lateral aspect of the pharyngeal 
vault. 

As described in the foregoing pages, the conducting 
mechanism consists of a canal, the walls of the central por- 
tions being osseous, while at either extremity they are fibro- 
cartilaginous, communicating upon one side with the outer 
surface of the body directly, while upon the other this com- 
munication is effected indirectly through the oral and nasal 
passages. This tube is brought into intimate relation with 
the receptive mechanism through the agency of the ossicular 
chain, and at this point the osseous conduit is dilated, forming 
the tympanum. This chamber, situated midway in the pas- 
sage, is occupied by a special device for bringing the two 
portions of the auditory apparatus into relation with each 
other. For the protection of the intratympanic parts chiefly, 
and, to a certain extent, to aid in the transmission of sonorous 
impulses, a fibrous partition divides the external auditory 
meatus from the tympanum and Eustachian tube. This parti- 
tion constitutes the membrana tympani. 

The Membrana Tympani. — The membrana tympani con- 
sists of a transverse fibrous septum, lying in the middle of the 
conducting tube, and bounded by the tympanic ring, which, 
it will be remembered, is incomplete at its upper part. This 
connective-tissue lamella, called the substantia propria of 
the drum membrane, is inserted into the sulcus tympanicus. 
At the point of insertion the fibrous tissue is somewhat thick- 
ened, forming the annulus tendinosus, sometimes called the 
cartilaginous ring. From the cartilaginous ring certain 
connective-tissue fibres extend outward to the periosteum of 
the meatus, while others, passing in the opposite direction, 
merge into the periosteal lining of the tympanum. The sub- 
stantia propria is made up of two layers. In the outer layer 
the fibres radiate from the tip of the malleus toward the 
peripheral wall, while in the internal layer they are disposed 
in concentric circles about this point as a centre. The manu- 
brium of the malleus joins the substantia propria through the 



22 THE ANATOMY AND PHYSIOLOGY OF THE EAR. 

interposition of a thin cartilaginous lamella which extends 
along its outer border from the processus brevis to the umbo, 
the fibres of the membrane being- continuous with the peri- 
chondrium of this cartilaginous plate. At the tip of the 
manubrium both the circular and radiating fibres are attached 
directly to the ossicle, while above this point, along the ex- 
ternal border, the attachment is effected through the interpo- 
sition of the cartilaginous plate above described. This carti- 
lage is firmly fixed at the tip of the manubrium, while the 
attachment at the short process is less firm and permits of a 
certain amount of separation from the short process. The 
superior border of the lamina propria joins the anterior and 
posterior extremities of the annulus tympanicus, constituting 
a tense, fibrous band, divided by the short process of the mal- 
leus into two parts. The sharply defined superior margin of 
the membrana propria extending from the processus brevis to 
the posterior extremity of the annulus is called the posterior 
fold The corresponding anterior fold is less prominent and 
shorter than the posterior. From the description it will be 
observed that the fibrous septum stretched across the canal 
is wanting where the curved outline of the annulus is com- 
pleted by the auditory plate of the temporal bone. This 
space is the Rivinian segment or notch, and its closure will 
be explained later, since it is effected by the cutaneous lining 
of the external auditory meatus. 

The Epithelial Investment of the Conducting Apparatus. 
— The auricle is covered with integument which is continuous 
with that of the face. It is somewhat loosely attached upon 
the posterior surface, but upon the anterior aspect is applied 
closely to the cartilage, the deep layer being intimately asso- 
ciated" with the perichondrium. The tegumentary covering 
of the auricle is continued into the external auditory meatus, 
its thickness decreasing as we pass inward, until in the bony 
canal its deep layer forms the periosteum. The cutaneous 
lining of the meatus along the supero-posterior wall is thick- 
er and more loosely attached than elsewhere, and is richly 
supplied with blood vessels. The covering of the superior 
wall of the canal passes from the internal margin of the audi- 
tory plate to the neck of the malleus, just above the short 
process, filling up the Rivinian notch and completely sepa- 
rating the external meatus from the tympanum. In com- 
parison with the remaining portion of the membrana tym- 



THE EPITHELIAL INVESTMENT. 23 

pani, it hangs somewhat loosely from the canal wall, and is 
called the membrana flaccida, or Shrapnell's membrane. Its 
fibrous layer is particularly well developed along the anterior 
and posterior borders, causing it to assume a somewhat tri- 
angular shape. These distinct fibrous bands constitute the 
fibres of Prussak. They extend from the anterior and pos- 
terior extremities of the Rivinian segment to the base of the 
processus brevis, and, passing along the manubrium, are lost 
in the external layer of the membrana propria. The space 
between the anterior ligament and the membrana flaccida is 
called Prussak's space. The epithelial covering of the meatus 
continues over Shrapnell's membrane, and covers completely 
the external surface of the drum membrane, forming its ex- 
ternal or epithelial layer. The auricle, the meatus, and the 
superficial layer of the membrana thus constitute an elon- 
gated blind pouch, not unlike the finger of a glove, the drum 
membrane answering to the closed tip of the glove finger. 

The integument of the auricle is supplied with sweat 
glands and sebaceous follicles. In the region of the tragus 
and antitragus, and for some distance within the cartilaginous 
canal, hair follicles are frequently found. The sebaceous 
glands in the meatus are somewhat altered in structure, con- 
stituting the ceruminous glands. These are not distributed 
beyond the junction of the cartilaginous meatus with the 
osseous portion, except for a small area along the upper and 
posterior wall, where they encroach slightly upon the bony 
canal. The glands are larger upon the upper wall of the canal, 
and are most numerous at the junction of the bony with the 
fibrocartilaginous portion. 

The tympanum and Eustachian tube are lined with mu- 
cous membrane continuous with that of the naso-pharynx. 
This membrane extends outward through the tube, covering 
its walls and forming the lining of the tympanum. It passes 
over the internal surface of the membrana tympani, constitut- 
ing its internal layer ; in various localities it is folded upon 
itself as it passes over the various intratympanic structures, 
giving rise to the so-called reduplications of mucous membrane 
within the tympanum. The most constant of these reduplica- 
tions constitute the anterior and posterior pockets of the mem- 
brana (Fig. 18), while other folds whose location and disposi- 
tion are not as constant are also met with. The lining in the 
cartilaginous portion of the Eustachian tube is thick and loose- 



24 THE ANATOMY AND PHYSIOLOGY OF THE EAR. 

ly attached, being thrown into Longitudinal folds in the lower 
part. In the osseous tube and tympanum it is closely applied 
to the underlying- structures constituting the periosteum. The 
epithelium is of the cylindrical ciliated variety in the tube and 
in the lower portion of the tympanic cavity, according to Po- 
litzer,* it changes to flat, ciliated epithelium above. 

The mucous membrane is supplied with mucous glands, 
which are extensively developed in the cartilaginous tube near 
the pharyngeal orifice, and diminish in number in the bony 
tube and tympanic cavity. In the middle ear they are mostly 
confined to the tubal orifice, although they are occasionally 
found over the promontory. The membranous portion of the 
Eustachian tube is quite richly supplied with lymphatic tissue, 
which occurs both in the diffuse form and, aggregated into 
masses, in the form of true lymphatic nodules. To these 
Gerlachf gives the name of tubal tonsil. The presence of 
this lymphatic tissue has also been demonstrated by Sappey4 
Ostmann, # and Teutleuben.| 

The Pockets of the Membrana Tympani and other Reduplica- 
tions of the Mucous Membrane (Figs. 18 and 19). — The pockets 
of the membrana tympani are the most constant of the re- 





-Wt: 



Fig. 18. — The pockets of Fig. 19. — The malleo - incudal 

the membrana tym- .articulation covered by the 

pani. (After Zuck- superior malleo-incudal fold, 

erkandl.) (After Zuckerkandl.) 

duplications which the lining of the cavity forms. The mu- 
cous membrane lining the tympanum is attached firmly to the 
drum membrane, to the bony internal wall, and to the walls 
of the irregular spaces which lie between the membrana tym- 
pani and the structures contained within the middle ear and 
in immediate relation with the membrane. After being re- 
flected over the contiguous bony and ligamentous parts it 

* Lehrb. der Ohrenheilk., Wien, 1893, p. 28. 
•f Arch, fur Ohren., vol. x, p. 53. 

I Traite d'anatomie descriptive, Paris, 1877, P- 865. 

# Virchow, Archiv, vol. xxxiv. 

|| Zeit. f r Anat. und Entwicklungsgeschichte, 1876, vols, iii and iv, p. 298. 



IiNTRATYMPANIC FOLDS. 25 

hangs downward into the tympanic cavity in folds somewhat 
like a curtain. The free borders of these folds are sharply 
marked and constitute the folds of the pockets. The anterior 
fold lies in front of the malleus, and the posterior behind it. 
The anterior pocket is the space included between the neck 
of the malleus behind, the annulus tympanicus in front, the 
membrana tympani on the outer side, and the spina tym- 
panica major and the anterior ligament on the inner side. At 
its apex it sometimes communicates with the chamber of 
Prussak. The posterior pocket is larger, and is traversed by 
the chorda tympani nerve and the posterior ligament of the 
malleus. Its free border — the posterior fold — may extend 
downward as far as the middle of the manubrium. This is a 
point of practical importance in middle-ear operations, since 
after the division of the membrana tympani, this fold, if ex- 
tensive, may completely hide the incus, to the long process of 
which it is frequently firmly attached. I have met with this 
condition several times, and unless one remembers the possi- 
bility of such an anomaly, its presence may prove a source of 
annoyance. In one case of exploratory tympanotomy per- 
formed under local anaesthesia, the posterior fold was long, 
thick, and adherent to the descending arm of the incus and 
to the membrana tympani. An incision through the mem- 
brana, instead of exposing the incudo-stapedial articulation, 
brought into view a thick vascular lamella of mucous mem- 
brane which demanded repeated incision before the long arm 
of the incus could be recognized or the inner Avail of the tym- 
panum seen. In another instance the fold was thin, but in- 
vested the incudo-stapedial articulation and long arm of the 
incus so completely that exploratory tympanotomy revealed, 
immediately after displacement of the flap, nothing but a 
smooth, glistening surface, which appeared to be the inner 
wall of the middle ear. No landmarks could be made out; a 
fact which showed that the inner tympanic wall had not been 
exposed, and it was not until the mucosa was divided by a 
vertical incision that the promontory and the niche of the 
round window could be seen. In acute inflammatory condi- 
tions I have seen exudation encapsulated in the tympanum 
on account of an anomaly in the posterior pocket. The boun- 
daries of the posterior pocket will be made clear by bearing 
in mind those of the anterior space, its exact analogue. 

The other mucous folds within the tympanum will not be 



26 THE ANATOMY AND PHYSIOLOGY OF THE EAR. 

described in detail on account of their endless variety, but a 
general account of their usual position and direction is neces- 
sary, since their presence is often of great importance both as 
affecting the outcome of inflammatory processes within the 
tympanum, and increasing the difficulty of certain operative 
procedures. These folds differ from the true ligaments only 
in their density. They have been extensively studied by 
Blake,* Bryant,f Zuckerkandl,^; and others. 

In general they may be classified, according to their direc- 
tion, as vertical or horizontal, and according to their situation, 
as those radiating from the axes of the long bones, those dis- 
posed about the stapes and the adjoining tympanic walls, and 
those stretching from the ossicular ligaments and the tendons 
of the intratympanic muscles to the ossicles and to the tym- 
panic walls. The horizontal folds may completely shut off the 
vault of the tympanum from the atrium, and the vertical folds 
may be so extensive as to inclose the entire ossicular chain 
except the manubrium of the malleus. 

The horizontal folds exert an important influence on acute 
and chronic inflammatory processes within the middle ear, 
their presence favoring the invasion of the mastoid process 
and cranial contents. The vertical folds not only act as ob- 
structors to the conduction of sound by their weight and by 
the increased tension which they cause, but are of great an- 
noyance to the surgeon in the performance of delicate opera- 
tions upon the tympanum, as they may completely hide 
important structures. Their presence, therefore, should be 
borne in mind in the consideration of all pathological pro- 
cesses within the middle ear, as in this way many appear- 
ances which are otherwise inexplicable may be correctly 
interpreted, or an operator may be able to accomplish an end 
which a hasty view of the cavity had led him to believe 
would be impossible. It need only be remembered that no 
hard-and-fast rule can be given for their location, and that 
almost any of the folds may occur together. 

The Muscles. — The muscles of the conducting mechanism 
include those passing from the auricle to the skull, the in- 



* Arch, of Otol., vol. xix, p. 209. 

f Ibid., p. 217. Burnett's System of Diseases of the Ear, Nose, and Throat, 
Philadelphia, 1893, vol. i, p. 55. 

\ Schwartzes Handbuch der Ohrenheilk., Halle, 1893, vol. i, p. 21. 



THE MUSCLES. 



2 7 



trinsic muscles of the auricle and canal, the intratympanic 
muscles, and those in the walls of the Eustachian tube. 

The auricle is bound to the skull posteriorly by the mas- 
toid fascia, the fibres of which interlace with the perichon- 
drium and fibrous tissue of the canal, and anteriorly by the 
temporal fascia, which is firmly attached to the helix. 

The extrinsic muscles are three in number, and are unim- 
portant in man, though in some of the lower animals they 
reach a high degree of development. They are the retrahens 
aurem, attollens aurem, and attrahens aurem. 

The ret? -aliens arises from the mastoid region by short 
aponeurotic fibres, and is inserted into the cartilage of the 
auricle upon its posterior and inferior aspect. Its point of 
origin is fixed only when the occipital portion of the occipito- 
frontalis is rigid. 

The attrahens arises from the epicranial aponeurosis at its 
lower border, and is inserted into the spine of the helix upon 
its cranial surface. 

The attollens arises from the occipito-frontalis aponeuro- 
sis. The fibres converge to the point of insertion upon the 
upper part of the cranial surface of the auricle. 

The intrinsic muscles consist of poorly developed bundles 
of muscular fibres distributed between the various cartilagi- 
nous processes of the auricle. Theoretically, their action 
would serve to alter the shape of the pinna, but from their 
imperfect development they are unimportant. They are 
situated chiefly upon the external surface of the organ. In 
the external meatus a few fibres of muscular tissue are found 
mixed with the fibrous bands which fill the incisures of San- 
torini. 

A muscular slip is occasionally found extending from the 
styloid process upward to the cartilaginous meatus. 

The intratympanic muscles are the tensor tympani and the 
stapedius. 

The tensor arises from the upper wall of the cartilaginous 
Eustachian tube and from the walls of the bony canal which 
inclose it. It enters the middle ear through an osseous con- 
duit at a point just above the tympanic orifice of the Eu- 
stachian tube, from which it is separated by a thin plate of 
bone — the processus cochleariformis. The tympanic extrem- 
ity of this process is pyramidal in shape, and is often called 
the anterior pyramid. The tendon winds about this projec- 



28 THE ANATOMY AND PHYSIOLOGY OF THE EAR. 

tion almost at a right angle, crosses the cavity of the middle 
ear, and is inserted along the inner border of the shaft of the 
malleus just below the neck, some of the fibres passing for a 
considerable distance down the manubrium, and spreading 
somewhat upon its anterior surface. 

The stapedius arises from the interior of the pyramid 
found upon the postero-internal tympanic wall in front of 
and below the aqueductus Fallopii. The fibres converge 
into a tendon which pierces the apex of the pyramid and is 
inserted into the neck of the stapes at the point of union with 
the posterior cms. 

The muscles of the Eustachian tube are the tensor palati, or 
spheno-salpingo-staphylinus, and the levator palati, or petro- 
salpingo-staphylinus. 

The tensor palati exerts the most influence upon the lumen 
of the Eustachian canal. It arises from the scaphoid fossa 
and spine of the sphenoid bone in front of the membranous 
portion of the tube, some of its fibres springing from the in- 
ferior border of the cartilaginous hook. The muscle then 
passes downward in front of the membranous portion of the 
canal, converging into a tendon which winds around the 
hamular process of the sphenoid and expands into a broad 
aponeurosis which is inserted into the anterior surface of the 
soft palate and into the posterior bony margin of the hard 
palate, the fibres uniting with those of the opposite side in 
the median raphe. 

The levator palati springs from the quadrilateral surface 
on the inferior aspect of the petrous bone, near its apex, and 
passes downward, forward, and inward to its insertion on the 
posterior and superior surface of the soft palate. The body 
of the muscle lies along: the inferior margin of the cartilasri- 

o o o 

nous plate which forms the posterior wall of the tube, to 
which it is loosely attached. It is also in contact with the 
fibrous inferior wall. 

A third muscle, sometimes included in this group, is the 
salpingo-pharyngeus, a muscular slip, which runs from the 
body of the palato-pharyngeus upward and forward to be 
inserted into the inferior wall of the tube. 

The Arteries (Plate I) of the conducting apparatus are de- 
rived chiefly from the external carotid artery, although a few 
branches spring from the internal carotid. The branches of 
the external carotid supplying the auricle, canal, and middle 



PLATE I 




The Arterial Supply of the Conducting Apparatus. 



THE ARTERIES. 



29 



ear are the posterior auricular, the superficial temporal, the 
occipital, the internal maxillary, and the ascending pharyn- 
geal. 

The posterior auricular is distributed to the posterior por- 
tion of the auricle and the corresponding part of the meatus. 
Through the stylomastoid branch which enters the stylo- 
mastoid foramen it supplies the mastoid cells, and sends a 
special branch to the stapedius muscle and to the stapes. It 
anastomoses with the superficial petrosal of the middle me- 
ningeal artery within the tympanic cavity, and with the tym- 
panic branch of the internal maxillary, forming with this lat- 
ter a complete vascular circle about the inner extremity of 
the meatus. 

The superficial temporal, through the superior and infe- 
rior anterior auricular arteries, supplies the anterior portion 
of the pinna and canal, the vessels anastomosing with the 
branches of the posterior auricular artery ; it also sends a 
small branch to the tympanum through the Glaserian fissure. 

The occipital artery sends branches to the concha, the ves- 
sels entering upon its cranial surface. 

The internal maxillary, through the middle meningeal and 
tympanic branches, is the most important source of blood 
supply, especially in early life. Before entering the cranium 
it sends a few twigs to the Eustachian tube. Within the 
skull it gives off the superficial petrosal, which enters the 
tympanum through the petro-squamous suture, and is dis- 
tributed to the roof of the middle ear, to the malleus and 
incus, and to a portion of the internal tympanic wall, where 
it anastomoses with the labyrinthine vessels, according to 
Politzer.* Within the Fallopian canal it communicates with 
the stylomastoid branch of the posterior auricular. 

The tympanic branch of the internal maxillary enters the 
middle ear through the Glaserian fissure, supplying the ante- 
rior portion of the cavity, and anastomoses with the stylo- 
mastoid branch of the posterior auricular upon the periph- 
ery of the tympanic membrane. In early life this artery is 
much larger than the stylomastoid, and the vascular circle 
about the margin of the membrane from which the numerous 
vessels pass outward to the posterior wall of the meatus 
seems to spring from the tympanic branch of the internal 

* Archiv fiir Ohrenheilk., vol. xi, p. 237. 



3 o THE ANATOMY AND PHYSIOLOGY OF THE EAR. 

maxillary ; hence this artery is sometimes called the auricu- 
laris profunda. 

On the internal wall of the middle ear the tympanic artery 
anastomoses with the tympanic branches of the internal carotid 
and with the Vidian branch of the internal maxillary. In ad- 
dition to the two branches of the internal maxillary named 
above, the Vidian, the descending palatine, and the pterygo- 
palatine arteries, all springing from this trunk, send small 
vessels to the Eustachian tube and to the tubal muscles ; the 
descending palatine anastomoses freely with the ascending 
palatine branch of the facial and with the ascending pharyn- 
geal branch of the external carotid artery. 

In its passage through the carotid canal the internal carotid 
sends branches to the tympanum, which anastomose with the 
tympanic and Vidian branches of the internal maxillary. 

The Veins (Plate II). — The veins are rather irregular in 
their distribution, but in general follow the course of the arter- 
ies. Most of the vessels from the deeper regions form a plexus 
upon the superior and supero-posterior walls of the external 
auditory meatus ; as they approach the orifice of the meatus 
the various venous channels anastomose freely with one an- 
other. Those on the posterior aspect of the canal and auricle 
pass into the external jugular and mastoid veins, while the an- 
terior branches go to join the temporal and facial veins. Some 
of the deeper vessels pass into the pterygoid plexus. The 
veins of the Eustachian tube follow the course of the arteries 
distributed to this region, and empty into the internal jugular 
directly, or occasionally communicate with the facial, the 
lingual, or the superior thyroid veins. Between the internal 
pterygoid muscle and the adjacent wall of the tube a trunk of 
considerable size establishes communication with the cavern- 
ous sinus ; near the pharyngeal orifice of the Eustachian ca- 
nal there is, according to Zuckerkandl,* a venous plexus com- 
municating with the turbinated bodies in the nasal cavities. 
The free anastomosis of the veins which return the blood 
from the deeper portions of the conducting mechanism is of 
particular importance from a therapeutic point of view, since 
this intercommunication between the various channels is 
comparatively superficial, and enables us to relieve deep- 
seated congestion by phlebotomy. The combined area of 

* Op. cit, p. 38. 



PLATE II 




The Venous Supply of the Conducting Apparatus. 



THE LYMPHATICS AND NERVES. 



31 



the veins is much greater than that of the arteries — a fact 
which in itself tends to cause the spontaneous resolution of 
any inflammatory process which may arise. Within the tym- 
panum the circulatory arrangement is somewhat unique, the 
capillaries being very short, or entirely wanting, and the 
arterial blood passes directly into the veins without the inter- 
position of the capillary system, as demonstrated by Prussak.* 

The Lymphatics. — The lymphatic channels are freely dis- 
tributed and anastomose both with the superficial lymph glands 
and with those forming the submucous lymphatic system of 
the pharynx. The superficial lymphatics over the mastoid, 
the lymph nodules in front of the auricle, and those situated 
in the cervical region between the platysma and the sterno- 
mastoid muscles are all intimately associated with the lym- 
phatic channels of the meatus and tympanum, while free 
lymphatic anastomosis exists in the opposite direction through 
the medium of the glands situated in the lateral pharyngeal 
walls. The lymph channels of the membrana tympani itself 
are arranged in three systems, one for each layer. These 
communicate freely with each other and with the lymphatic 
network of the external meatus. 

The Nerves (Figs. 20 and 21). — The muscles of the con- 
ducting apparatus derive their innervation from the trige- 
minus, the facial, and the cervical plexus. The cervical plexus, 
through the occipitalis minor, supplies the attollens aurem ; 
the trigeminus, through the otic ganglion, supplies the tensor 
tympani and the tensor palati muscles ; the facial supplies 
the other muscles, either directly or through its ganglionic 
communications. 

The sensory nerves are derived from the cervical plexus, 
trigeminus, pneumogastric, and the glosso-pharyngeai trunks. 
The auriculotemporal, a branch of the trigeminus, supplies 
the auricle, the upper part of the meatus, and the membrana 
tympani. The auricularis magnus, from the cervical plexus, 
is distributed principally to the posterior part of the auricle 
and meatus, anastomosing with the auricular branch of the 
pneumogastric upon the posterior wall of the canal. 

The auricular branch of the vagus supplies the cartilagi- 
nous canal and a portion of the posterior surface of the auricle. 
The tympanic branch of the glossopharyngeal enters the mid- 

* Archiv fiir Ohrenheilk., vol. iv, p. 290. 



j- 



die car through a foramen in the floor of the cavity, and 
is distributed to its lining membrane and to the Eustachian 
tube. Upon the internal tympanic wall it divides. One 
branch anastomoses with the fibres of the carotid plexus from 
the sympathetic system, forming the tympanic plexus; an- 
other nerve twig, the small deep petrosal, passes through a 
bony foramen in the tegmen tympani to the small superficial 
petrosal nerve, which is the facial tributary to the otic ganglion ; 
a third emerges from the cavity to join the great superficial 
petrosal, which is the facial root of the Vidian nerve, the pos- 
terior branch of Meckel's ganglion. This branch is called 
the great deep petrosal. 

Briefly, we may describe this complex nervous anastomo- 
sis as follows : The glossopharyngeal, through its tympanic 




Fig. 20. — The nerves of the conducting mechanism, and their anastomotic branches. 



branch, anastomoses with branches from the carotid plexus, 
upon the internal wall of the middle ear, forming the tym- 
panic plexus ; from this plexus two branches are given off, 
one communicating with the otic ganglion, the other with 
Meckel's ganglion. 

We have yet to mention the chorda tympani, which, emerg- 
ing from the aquaeductus Fallopii above the pyramid, crosses 
the tympanic cavity from behind forward, passing between the 
long process of the incus and the manubrium of the malleus. 
It leaves the middle ear through a separate canal which lies 



THE RECEPTIVE MECHANISM. 



33 



close to the Glaserian fissure, and joins the lingual branch of 
the trigeminus. 

It can not but be noticed how richly the conducting ap- 
paratus of the ear is supplied with nerves, especially in the 
deeper and more delicate parts. More will be said upon this 
subject in considering the physiology of the conducting mech- 




Fig. 21. — The nerve distribution within the tympanum. 

anism, but the free anastomosis between the various nerves 
should be particularly borne in mind, for it is due to this fact 
that changes within the external or middle ear or Eustachian 
tube may give rise to remote symptoms, and that these re- 
gions may themselves be the seat of reflex disturbances. 

II. The Receptive Mechanism. 

We have now described that part of the apparatus of 
audition, concerned in the transmission of sonorous vibrations 
from without, to the point where they are brought into im- 
mediate relation with the end organ of the auditory nerve. 
Let us next consider the structures concerned in the inter- 
pretation of these sonorous vibrations. 

For reasons already given, we include under this general 
term, not only the internal ear, but also the auditory nerve 
and its centers of origin, as well as the various avenues of 
communication with other centers, and with the correspond- 
ing nuclei of the opposite side and with the cortical area of 
audition in the brain. 
4 



34 THE ANATOMY AND PHYSIOLOGY OF THE EAR. 

For convenience of description, the course of the auditory 
nerve will be followed from the specialized end organ found 
in the labyrinth, inward toward its origin, rather than in the 
opposite direction, which would be more strictly correct from 
an anatomical point of view. 

The internal ear comprises the osseous and membra- 
nous labyrinth, the former being- a series of communicating 
chambers tunneled in the petrous portion of the temporal 
bone and filled with fluid, in which the membranous labyrinth 
is suspended. This latter structure consists of a series of 
membranous tubes, also rilled with fluid, called the endolymph. 
They follow the general contour of the osseous passages in 
which they lie, but do not completely fill them, the interven- 
ing space being occupied by the perilymph. 

The Bony Labyrinth (Fig. 22).— The bony labyrinth may 
be described as a central chamber in the petrous portion of 




Fig. 22. — The bony labyrinth. (Riidinger, Blake's translation.) i, Round window; 
2, Lamina spiralis ossea ; 3, Osseous cochlear canal ; 4, Floor of internal audi- 
tory meatus ; 5, Vestibule ; 6, 7, 8, 9, Semicircular canals. 

the temporal bone, called the vestibule, from which various 
tortuous channels diverge. This central chamber is ovoid in 
shape, the vertical diameter being the greater and measur- 
ing about one fourth of an inch, while the short diameter is 



THE BONY LABYRINTH. 35 

about one fifth of an inch. On its outer wall it presents a 
kidney-shaped opening, which under normal conditions is 
closed by the foot plate of the stapes. The inner wall ex- 
hibits two fossas, separated by a bony spine called the crista 
vestibuli. The anterior depression, which is occupied by the 
saccule, is the recessus sphericus ; the posterior, lodging the 
utricle, is the recessus ellipticus. The posterior w r all presents 
the openings of the three semicircular canals ; these openings 
are five in number, two canals, the superior and posterior 
entering the vestibule by a common channel. The entrance 
to the cochlear canal takes the place of the anterior wall of the 
vestibule. On the inferior internal wall, close to the border 
of the recessus ellipticus, there is a small opening, the orifice 
of the aquaeductus vestibuli. Through this channel the cav- 
ities of the membranous labyrinth communicate with the 
subdural space. 

The semicircular canals are three in number, and are so 
disposed that the plane of each canal is perpendicular to 
that of the other two ; they are denominated the superior, 
posterior, and external canals. The superior lies in the ver- 
tical plane of the long axis of the petrous portion of the 
temporal bone. The posterior is placed at right angles 
to this, and is also vertical, while the external canal lies in 
the horizontal plane. As the name implies, each of these bony 
passages bends upon itself to form a semicircle, the point of 
origin and termination being the vestibule. The superior 
and posterior canals terminate in this cavity by a common 
opening, but with this exception each communicates with the 
vestibule by two openings, one of which may be considered 
the source and the other the terminus. Where the outer ex- 
tremity of the external canal enters the vestibule the lumen 
of the passage becomes dilated, forming what is known as an 
ampulla. The unjoined vestibular extremities of the posterior 
and superior canals are also ampullated. 

The Cochlea. — The entrance of this passage lies at the 
anterior and inferior aspect of the vestibule. It consists of a 
bony tube coiled two and a half times about an osseous axis 
— the modiolus. From the modiolus a thin septum of bone 
— the lamina spiralis — made up of two thin bony plates, ex- 
tends into the lumen of the tube, partially dividing it into 
two channels. This bony partition does not extend com- 
pletely across the canal to the outer wall, the intervening 



36 THE ANATOMY AND PHYSIOLOGY OF THE EAR. 

space being bridged by a membranous septum, which com- 
pletes the division of the cochlear tube. This fibrous septum 
is called the lamina spiralis membranacea. The lamina spi- 
ralis at its free border divides into a superior and inferior 
limbus. The space inclosed by this separation is called the 
sulcus laminae spiralis. At the apex of the cochlea the par- 
tition which divides the canal into two distinct channels is 
incomplete ; the termination of the septum is somewhat 
hook-shaped, forming the hamular process, while the passage 
of communication between the superior and inferior spaces 
is called the helicotrema. The terminal half-turn of the coch- 
lea forms the cupola, and in this region the lamina spiralis 
ossea, just before its termination, is twisted upon itself in 
such a manner as to inclose a funnel-shaped space called 
the infundibulum. 

The modiolus is traversed by numerous canals, the larg- 
est running through its axis and named the canalis cen- 
tralis modioli, from which secondary channels diverge into 
the lamina. At the junction of the modiolus with the lamina 
a canal ascends spirally between the layers of this bony sep- 
tum, passing to the very apex of the cochlea. This is 
called the canalis spiralis modioli. The lamina spiralis ossea, 
with the membranous lamina, divides the bony cochlea into 
two passages, as already stated. The lower is called the 
scala tympani, the upper the scala vestibuli. The modiolus 
and the lamina are so disposed that the scala tympani does 
not communicate with the vestibule, but leads into the tym- 
panic cavity at the round window. In fact, we may consider 
the cochlear canal as beginning at the fenestra rotunda, at the 
inferior external angle of the vestibule, the wall at this point 
forming the modiolus. As the first turn passes forward and 
then upward from the round window, the contiguous walls of 
the tube and of the vestibule amalgamate and form a partition 
extending into the tube, which divides it into two channels, 
the upper of which communicates with the vestibule. The 
bony partition thus formed does not extend entirely across 
the tube, and the septum is completed by the membranous 
spiral lamina. Just beyond the round window in the floor of 
the scala tympani a narrow canal extends to the inferior sur- 
face of the petrous bone. This is the aquseductus cochleae, and 
can be traced to the subarachnoid lymph space ; it affords an 
avenue of communication between the perilymph and the 



THE MEMBRANOUS LABYRINTH. 37 

intracranial lymph sac. After the lamina spiralis ossea sepa- 
rates into two thin plates of bone, each is continued as a 
membranous septum as far as the outer wall of the cochlea. 
Here, by their divergence, they inclose a triangular space, 
which extends from the round window to the apex of the 
cochlea, in a spiral direction ; this space, converted into a tube 
by the outer wall of the cochlea, is called the cochlear canal 
or scala media. Where the diverging septa join the outer 
bony wall of the cochlea the periosteum is thickened and 
richly supplied with blood vessels, especially where it joins 
the lower lamella, where it is called the ligamentum spirale. 

That portion of the membranous septum which is con- 
tinuous with the inferior lamella of the osseous spiral lamina 
passes outward in the same plane as the lamina spiralis ossea, 
and becomes the membrana basilaris. The upper leaflet 
forms an acute angle with this, and is called the membrane of 
Reissner. 

The manner of formation and the course of the various 
channels having been described, we have next to consider 
the lining membrane. 

The walls of the osseous canals and vestibule are covered 
by delicate fibrillated connective tissue rich in nuclear ele- 
ments ; this is applied closely to the osseous walls, constituting 
the periosteum. Its surface is covered with flat endothelial 
cells. The lumen of the bony semicircular canals or peri- 
lymphatic space is traversed by delicate bands of the con- 
nective-tissue covering of the osseous walls, which pass to the 
outer wall of the membranous canals, thus dividing the peri- 
lymphatic space irregularly. At the point of attachment of 
the membranous canals to the walls of the passage their lin- 
ing membrane is thickened. 

The Membranous Labyrinth (Fig. 23). — The membranous 
labyrinth consists of a series of tubes, formed of delicate con- 
nective tissue, lying within the bony channels already de- 
scribed. The membranous simicircular canals terminate in the 
utricle, which lies in the recessus ellipticus vestibuli, while the 
membranous cochlea is joined to the saccule by a very narrow 
canal, called the canalis reuniens Hensenii. This entire series 
of tubes is filled with a clear fluid known as the endolymph. 
Thus far we have described two series of channels, contain- 
ing fluid, terminating in somewhat spherical chambers — the 
utricle and saccule. The membranous cochlea terminates in 



38 THE ANATOMY AND PHYSIOLOGY OF THE EAR. 

a blind pouch (the lagena) at the apex of the bony passage 
in which it lies. From the adjacent aspects of the utricle and 
saccule a delicate canal is given off which coalesces into a 
common channel — the ductus endolymphaticus. This trav- 
erses the aquseductus vestibuli and terminates in a blind sac 
(the recessus of Cutogno) upon the posterior surface of the 
petrous bone beneath the dura. According to Rudinger,* 
the endolymph may pass to the dural lymph spaces through 
this canal. The saccule and utricle lie upon the internal wall 




Fig. 23. — Adult membranous labyrinth (osmic-acid preparation). (Retzius.) /, La- 
gena ; lis, Spiral ligament ; mb, Basilar membrane ; sv, Stria vascularis ; mis, 
Membrana tympani secundaria ; esc, Canalis reuniens ; s, Lower end of saccule ; 
cus, Canalis utriculo-saccularis ; de, Ductus endolymphaticus ; s/>, Posterior utricu- 
lar sinus ; rec, Recessus utriculi ; aa, ae, ap, Ampullae of anterior, external, and 
posterior canals ; vb, Vestibular cul-de-sac ; ca, cc, cp, Semicircular canals ; ss, 
Union of posterior and superior canals ; rb, rap, rs, ru, raa, rac, Branches of 
auditory nerve to various portions of membranous labyrinth ; ms, Macula acus- 
tica of saccule ; f, Facial nerve. 

of the bony vestibule, but do not fill the cavity completely, 
considerable space being left between them and the outer 
wall. The intervening space is filled with perilymph, and is 
called the cistema lvmphatica. It is of practical importance 
to remember that the distance from the inner surface of the 
foot plate of the stapes to the opposite wall of the membra- 
nous labyrinth is about three millimetres, or one eighth of an 
inch. In the same manner the lumen of the bony cochlea 



* Arch, fiir Ohrenheilk., vol. xxvii, p. 222. 



THE SACCULE AND UTRICLE. 39 

and semicircular canals is not completely rilled by the con- 
tained membranous structures ; these latter are attached to 
the bony walls along the line of their convexity, and the 
periosteum is thickened along this line. Additional support 
is afforded the semicircular canals by bands of connective 
tissue which pass from the outer wall of the membranous 
channel to the osseous walls. 

Regarding the microscopical structure of the membranous 
labyrinth, it may be described as made up of a framework of 
connective tissue, the outer surface being covered by a reflec- 
tion of the endothelial layer which lines the bony labyrinth. 
The lining of the irregular cavity is of much greater interest, 
since it constitutes the special end organ of the auditory 
nerve. 

The Saccule and Utricle. — Upon the internal surface of the 
saccule and utricle, in the region corresponding to their at- 
tachment to the bony vestibular wall, there is a mound or 
papilla which encroaches somewhat upon the lumen of the 
cavity. This papilla is called the macula acustica, and is 
formed by the aggregation of the cells which form the lining 
of the space, the epithelium changing from the polygonal 
pavement variety to the cuboidal, and then to the cylin- 
drical form as it approaches the region of the macula. The 
papilla itself is covered by a specialized epithelium, the cells 
appearing under two forms, either as ciliated or hair cells, or 
as supporting cells placed between those before named. The 
supporting cells have large nuclei, and are either cuboidal be- 
low near the base, sending a delicate process to the surface, 
or they are fusiform, the nucleus lying near the centre. They 
terminate in elongated processes, one of which lies upon the 
surface of the papilla, the other passing to the basement 
membrane. 

The hair cells are elongated protoplasmic masses, each 
with an ovoid base, from which the body gradually tapers to 
a constricted portion called the neck, just below the superior 
extremity ; above this, the cell again becomes broad. From 
the free extremity of each cell, ten to twelve cilias project 
into the cavity ; these are called the auditory hairs. Ac- 
cording to Kaiser,* whose description I have most closely 
followed here, the body of each hair cell is completely sur- 

* Arch, fur Ohrenheilk., vol. xxxii, p. 181. 



4 o THE ANATOMY AND PHYSIOLOGY OF THE EAR. 

rounded by a delicate envelope, formed by the expansion of the 
axis cylinder of a single nerve fibrilla, although the axis cylinder 
cannot be traced with certainty into the cell body. The sur- 
face of the macula acustica constitutes the membrana limitans; 
this is reticular in structure, and through its spaces the audi- 
tory hairs project. In hardened specimens the auditory hairs 
are usually matted together, and the macula appears to be cov- 
ered by a finely fibrillated gelatinous substance, in which some 
of the ciliary processes can be made out. Lying between the 
ciliae, upon the surface of the macula we find an aggregation 
of minute crystals — the otoliths — apparently imbedded in the 
structureless covering of the mound. The agglutination of the 
auditory hairs is probably due to changes effected in the en- 
dolymph by fluids used in hardening the specimens. The 
macula acustica of the utricle and saccule are identical in 
structure. In the ampullae similar papillae are found, and are 
here called the cristas acusticae. The cristae acusticae are 
smaller than the maculae acusticae, their hair cells are also 
less developed, and the individual ciliae can not be made out. 
In hardened specimens the apex of the crista has the same 
structureless appearance as that of the macula, the homo- 
geneous substance surmounting it being here called the cu- 
pula. The appearance is probably due to the action of the 
hardening fluids upon the endolymph. The membranous 
canals are lined with polygonal pavement epithelium, and 
present, at various portions of their course, a papillary struc- 
ture. No nerve elements have been traced to the interior of 
the canals. 

The Membranous Cochlea or Scala Media. — This passage is 
joined to the saccule by the canalis reuniens Hensenii, and 
consists of a membranous tube, triangular on cross section, 
inclosed between the membrane of Reissner above, and the 
membrana basilaris below. Its outer wall is formed by the 
endothelial lining of the bony cochlea. At its lower extremity 
the canal terminates in a blind pouch at the round window, 
the caecum vestibuli, the basilar membrane completely shut- 
ting it off from the vestibule. The superior blind extremity is 
called the lagena. The superior and inferior walls are formed 
by a continuation of the divergent lips of the osseous spiral 
lamina, each of which becomes membranous after the division 
of the bony partition into two plates, and extends to the op- 
posite bony wall of the cochlea. The inferior membranous 



THE MEMBRANOUS COCHLEA. 41 

wall or floor is called the membrana basilaris. At the sulcus 
spiralis, the basilar membrane becomes much thickened, form- 
ing the limbus laminae spiralis, or crista spiralis. This separates 
into two lips, the furrow thus formed being called the sulcus 
spiralis internus. This groove is lined with cuboidal epithe- 
lial cells which pass upward to the vestibular lip. The basilar 
membrane stretches from the tympanic lip of the crista spira- 
lis to the spiral ligament ; it is made up of tightly stretched 
transverse fibres, the length of the successive fibres increas- 
ing from the base of the cochlea to the apex. The tympanic 
surface of the membrana basilaris is covered with polygonal 
pavement epithelium continuous with the lining of the scala 
tympani. 

The epithelium of the upper surface of the basilar mem- 
brane is cuboidal for a short distance beyond the sulcus spi- 
ralis internus ; the cells then become successively columnar, 
and farther outward undergo certain changes (to be de- 
scribed later), as a result of which there appears to be a ridge 
along the surface of the basilar membrane. Closer inspection 
shows that this ridge is really a series of arches. Beyond 
this ridge the cells again become cuboidal. This longitudi- 
nal ridge, which is continuous along the central portion of the 
basilar membrane from the round window to the lagena, ap- 
pears as a papilla in a vertical section of the cochlea, and is 
called the papilla acustica or zona tecta of the membrane ; 
the outer portion is called the zona pectinata, and the inner 
the zona perforata. The epithelium of the zona perforata is 
cuboidal and pierced with nerve fibres which reach it by 
passing outward from between the lips of the osseous lamina. 
Where it joins the zona tecta the cells become columnar, and 
are called the inner supporting cells. Next to these is a sin- 
gle row of elongated cells terminating above in ciliae ; these 
are the inner hair-cells. Beyond the inner hair-cells lie the 
inner rods of Corti, which rise from the basilar membrane, 
and form, with the outer rods, an arch called Corti's arch. 

This arch can be plainly seen in microscopic specimens (see 
Fig. 24) when the sections are made perpendicular to the basi- 
lar membrane, since it extends throughout the entire length of 
the cochlea. These successive arches form a closed passage 
or tunnel from the lowest portion of the cochlea to its apex, 
covering over the portion of the membrana basilaris between 
the bases of the inner and outer rods. The inner rods arise 



42 THE ANATOMY AND PHYSIOLOGY OF THE EAR. 

from a broad base and extend upward and outward at an 
angle of about sixty degrees. Immediately above the base 
the cells become narrow, transparent, and structureless; they 
terminate in a club-shaped upper extremity or head, which is 
hollowed out on its outer aspect for the reception of a corre- 
sponding rounded process upon the outer rods. From the 
head of each inner rod a process extends horizontally inward, 
separating the adjacent hair cells. The outer rods are more 
numerous than the inner, and make an angle of about forty- 
five degrees with the basilar membrane; they are longer than 
the inner rods, but of the same shape, and their club-shaped 
heads fit into the articular process upon the outer surface of 
the head of the corresponding inner rod. The outer cells 
being greater in number than the inner, each member of the 




Fig. 24. — Vertical section of the membranous cochlea. (Retzius.) cs, Limbus laminae 
spiralis ; mc, Membrane of Corti ; si, Sulcus internus ; is, Inner supporting 
cells ; ic, Inner rods ; ih, Inner hair-cells ; ah^-ak^, Outer hair-cells ; dz, Dei- 
ters's cells ; as, Supporting cells of Hensen ; rb, Nerve fibres ; n x -rfi, rf, Nerve 
fibres to hair-cells ; at, Nuel's space ; mb, mb 1 , tb, Basilar membrane ; lis, Spiral 
ligament. 

latter series supports two or three of the external fibres of 
Corti. Beyond the outer rods there are found from three 
to five rows of hair-cells, of the same general structure as 
those observed in the zona perforata. They rise, however, 
almost perpendicularly from the basilar membrane, thus leav- 
ing a space between the outer rods and the inner row of hair 
cells, known as Nuel's space. The rows of outer hair-cells 
are separated from each other by the cells of Deiters. These 
are broad at their base, but narrow 7 as they approach the sur- 
face, and are marked along their inner border by a bright 
line which runs the entire length of the cell from the upper 
to the lower extremity. The upper extremity of this bright 
line, called the supporting fibre, terminates in a delicate 
lamella or phalanx ; the contiguous phalanges form by their 



THE MEMBRANE OF CORTI. 



43 



union a reticular membrane, through the interstices of which 
the outer hair-cells project. Beyond the cells of Deiters the 
epithelium again becomes columnar, forming the outer sup- 
porting cells, beyond which it resumes gradually the form 
found in the zona pectinata. 

The membrana reticularis is formed by the union of the 
phalanges of the supporting fibres of Deiters's cells ; its outer 
limit is poorly defined. It passes inward from the inner row 
of Deiters's cells to the summit of Corti's arch, to which it is 
attached. 

The Membrane of Corti, or Membrana Tectoria. — This is 
a gelatinous membrane arising from the upper border of the 
sulcus spiralis internus, just below the attachment of Reissner's 
membrane, and extending outward, over the papilla acustica, 
beyond the outer row of Deiters's cells ; it is intimately con- 
nected with the hair-cells, but in exactly what manner is still 
a mooted question. The hair cells are supposed to be the 
specialized end organ of the cochlear nerve ; the nerve fibres 
pass through the zona perforata as naked axis cylinders, and 
have been traced by Katz * to the interior of the inner hair 
cells. Delicate fibrillar also cross beneath the arch of Corti, 
and have been traced to the outer of Deiters's cells and to 
the outer hair cells which they probably enter, although this 
is not certain. 

Having described the peripheral termination of the au- 
ditory nerve, we will next follow its fibres backward to the 
main trunk. 

From the cochlear hair-cells the filaments pass inward be- 
tween the layers of the osseous spiral lamina, resume their me- 
dullated layer, and unite to form the cochlear branch of the 
auditory nerve in the tubulus centralis modioli. Where the 
fibres of distribution radiate from the central trunk within the 
modiolus a ganglionic enlargement is found, called the spiral 
ganglion. From the cristas acusticas and maculae acusticas 
the nerve filaments pass through minute foramina in the walls 
of the bony labyrinth. The nerve filaments unite to form the 
vestibular branches of the auditory nerve, the fibres from the 
saccule forming the inner branch, those from the utricle and 
ampulla of the external and superior canals the superior 
branch, and those from the ampulla of the posterior canal the 

* Arch, fur Ohrenheilk, vol. xxix, p. 54. 



44 



THE ANATOMY AND PHYSIOLOGY OF THE EAR. 



inferior branch. These foramina constitute the macula cri- 
brosa of the fovea spherica, and fovea elliptica. 

The Blood Supply of the Labyrinth (Plate III).— The 
Arteries. — The blood supply is derived from the internal audi- 
tory artery, a branch of the basilar. The artery accompanies 
the auditory nerve to the labyrinth, where it divides into two 
branches, the one supplying- the vestibule and semicircular 
canals, the other following the cochlear branch of the nerve to 
the cochlea, where minute vessels pass outward, forming an 
arterial plexus for the supply of the membranous cochlea. The 
minute vessels radiate from the larger arterial twigs toward 
the outer labyrinthine walls of the scala vestibuli and scala tym- 
pani, but are most prominent in the walls of the scala vestibuli. 

The Veins. — The veins follow the same general course as 
the arteries, the smaller branches uniting to form three main 
channels — the vein of the cochlear aqueduct, the vein of the 
aquasductus vestibuli, and occasionally a third vessel is found, 
the internal auditory vein, although this is the least constant 
branch. 

The vein of the aquasductus cochleas passes through the 
cochlear aqueduct to the internal jugular. The vestibular vein 
joins the superior petrosal sinus, leaving the labyrinth through 
the aquasductus vestibuli, while the internal auditory vein ac- 
companies the artery of the same name and empties into either 
the transverse or inferior petrosal sinus. 

The terminal branches of the venous channels anastomose 
freely with one another, forming spiral plexuses or loops. In 
general, it may be said that the blood current enters the laby- 
rinth upon one aspect, and, instead of forming a complete cir- 
cuit and finding an exit in the same region, passes out on the 
opposite side of the labyrinthine cavity, the chief avenue of 
venous discharge from the cochlea being the vein of the coch- 
lear aqueduct. 

Boettecher* describes a capillary twig running along the 
tympanic surface of the basilar membrane under the arch of 
Corti, which he calls the vas spirale of the cochlea. Its exist- 
ence has been denied by Berthold,fand Siebenmann.J Eichler* 

* Arch, fur Ohrenheilk, vol. xxiv, p. i. 

f Schwartze's Handb. der Ohrenheilk., 1893, vol. i, p. 711. 
\ Arch, fur Ohrenheilk., vol. xxxv, p. 115. 

* Abhandl. d. math. phys. Klasse der k. sach. Gesell. der Wissenschaft des physi- 
olog. Inst, zu Leipzig, 1892, vol. xviii, No. 5, p. 311. 



PLATE III. 




The Vascular Supply of the Cochlea. (Modified from Hyrtl.) 



THE AUDITORY NERVE. 45 

has made important investigations upon this subject, from 
which it seems probable that the capillary spiral plexus is 
formed by the cochlear vessels both in the sulcus internus 
and upon the tympanic surface of the basilar membrane be- 
neath the arch of Corti. The spiral plexus is particularly 
prominent in the lower turn of the cochlea. A somewhat 
similar anastomosis exists also in the ligamentum spirale. 

According to Siebenmann's investigations, the internal au- 
ditory artery usually divides into three branches — the coch- 
lear, vestibular, and vestibulocochlear — the particular por- 
tions supplied by each branch being sufficiently indicated by 
their respective names. The particular manner in which the 
trunk divides is of but small practical importance, but we 
should remember that the blood supply of the lower turn of 
the cochlea is much more abundant than that of the upper 
portions of the spiral. 

If a vertical section is made through the cochlea, it will be 
found that the arterial trunks lie chiefly in the walls of the 
scala vestibuli, as already mentioned, while the venous chan- 
nels are mostly confined to the walls of the scala tympani. 
This arrangement is shown diagrammatically in Plate III, 
from which it will be seen that the arterial capillaries pass 
into the venous in the region of the ligamentum spirale. 

The Auditory Nerve (Plate IV). — The auditory nerve 
trunk constitutes the portio mollis of the older anatomists, 
and is given off from the medulla at the posterior border of 
the pons Varolii. It arises from two roots, the lateral or an- 
terior, constituting the vestibular nerve, while the internal or 
posterior fibres form the cochlear portion. 

The Cochlear Nerve. — The posterior root, called also the in- 
ternal, constituting the cochlear nerve, arises from a large- 
celled nuclear mass in the medulla (the anterior or ventral nu- 
cleus) and from a smaller aggregation of cells lying to the 
outer side of this, the tuberculum acusticum. From the ven- 
tral nucleus of each side two bundles of fibres are given off, 
one of which is of large size and passes to the olivary body of 
the opposite side, the other, of smaller dimensions, to the olivary 
body of the same side. The crossed fibres by their decussa- 
tion constitute the corpora trapezoides, a name applied on ac- 
count of the peculiar appearance which they give to a section 
of the medulla in this region. From each olive four sets of 
fibres are given off. The larger number pass to the posterior of 



46 THE ANATOMY AND PHYSIOLOGY OF THE EAR. 

the corpora quadrigemina through the fillet, a small bundle 
passes to the spinal cord, a third passes to the region of the 
abducens nucleus and communicates with it, while a fourth 
bundle of fibres passes to the cerebrum. From the tubercu- 
lum acusticum a small bundle of fibres crosses the median 
line to the opposite fillet, uniting with those which pass be- 
tween the olivary body and the posterior of the corpora quad- 
rigemina of this side. 

To recapitulate briefly, most of the fibres from either 
cochlear nerve pass to the opposite side of the brain through 
the trapezoid bodies to the opposite olive, then through the 
fillet to the posterior quadrigeminal body, accompanied by a 
few filaments from the tuberculum acusticum. A small pro- 
portion of the fibres in the cochlear nerve in question do not 
cross, but pass to the cortical centres of the corresponding 
side of the brain through the olive of this side. The course 
of the fibres from the corpora quadrigemina has not been defi- 
nitely made out, although the position of the nuclei in the 
medulla and the decussation of the fibres has been verified 
by physiological experiment. After entering the corpora 
quadrigemina the fibres are supposed to pass to the poste- 
rior third of the internal capsule, and from there to the first 
and second temporal convolutions, this being the auditory 
centre in the cortex according to the most recent investiga- 
tions. 

The Vestibular Nerve. — The vestibular nerve arises from 
the internal or dorsal nucleus, close to the vagus centre, but 
superficial to this. Branches originating in this collection of 
nerve cells cross the raphe, embracing in their course the 
nucleus of the sixth nerve and pass to the cerebral cortex, 
although the exact course which they follow is undetermined. 
A large fasciculus extends to the cerebellum, passing first 
through the pons, then the vermis, and finally terminates in 
the corresponding cerebellar hemisphere and in that of the 
opposite side. The dorsal nucleus communicates with the 
spinal cord through a fasciculus which passes downward and 
inward between the olivary bodies. 

Besides the cochlear and vestibular roots, the auditory 
trunk contains a bundle of fibres which emerge between the 
roots already described. These arise from an aggregation of 
cells, called Deiters's cells, lying in the medulla between the 
anterior nucleus and the olivary body. The branches of com- 



PLATE IV. 




The Auditory Nerve. (Modified from Freud.) 



THE AUDITORY NERVE. 



47 



munication with the other nuclei of the eighth nerve and with 
other cerebral centres are undetermined. 

We thus appreciate the complexity of the central portion 
of the acoustic apparatus, and may realize what manifold 
causes may exist for impairment or perversion of function. 
We must bear in mind that any disturbance of audition of 
nervous origin may be variously located at any point between 
the cochlea, which represents the end organ of the auditory 
nerve, and the first and second temporal convolutions of the 
cerebrum, which represent the cortical auditory area. The 
fibres from the cochlea of either side, according to our descrip- 
tion, pass through the cochlear nerve to the ventral nucleus 
and to the tuberculum acusticum, most of the fibres passing 
to the superior olive of the opposite side through the corpora 
trapezoides, and then to the corresponding posterior quadri- 
geminal body through the fillet; thence to the posterior third 
of the internal capsule, and thence to the first and second 
temporal convolutions. A smaller collection of fibres from 
the anterior or ventral nucleus passes to the olive of the same 
side, through the trapezoid body and to the cortical area of 
this side, following a course similar to that pursued by the 
fibres from the opposite olivary body ; from this olivary 
body other fibres pass to the cerebellum, to the spinal cord, 
and to the abducens nucleus. 

The portion of the cochlear nerve terminating in the tuber- 
culum acusticum sends a few decussating fibres to the oppo- 
site fillet, its only other communication being that afforded 
by its immediate proximity to the anterior nucleus. 

The vestibular nerve twigs amalgamate into a trunk, which 
terminates in the internal or dorsal nucleus, from which fibres 
pass to the spinal cord, to the cerebellar hemisphere of the 
same, and to that of the opposite side, and probably to the 
opposite cerebral hemisphere. The communication with the 
cerebellum is the most extensive, and this portion of the brain 
constitutes the important terminus of the vestibular branch 
of the auditorv trunk. 



CHAPTER II. 

THE PHYSIOLOGY OF THE EAR. 

In order to understand the manner by which sound per- 
ception is effected, it will be well to recall the physical prin- 
ciples involved in sound production and transmission. 

Sound is a mode of motion produced by the vibration of 
matter. Vibrations are transmitted to the organ of hearing 
through any elastic medium. If the vibrations succeed each 
other at regular intervals and with sufficient rapidity they 
affect the ear collectively, rather than as separate impulses, 
and produce what is known as a musical sound. If the im- 
pulses are irregularly repeated, or if the interval between 
each is of considerable duration, the impression constitutes 
a noise, each act of transmutation of energy into motion 
producing an effect upon the receptive centres. When the 
impulses follow each other at a rate of less than sixteen per 
second they are observed singly ; but if at a greater rapidity, 
the sound becomes musical and continuous. According as 
the rate of, vibration is slow or rapid, the note is of low or 
high pitch, until finally the vibrations follow each other so 
rapidly that the ear no longer appreciates them. From this 
we see that the ear possesses certain limits of perception for 
musical sounds, between which all regularly recurring vibra- 
tions impress the organ in a certain definite way. These 
limits are called the tone limits of the ear, and range from 
about sixteen double vibrations per second to thirty-two thou- 
sand five hundred double vibrations per second. 

It will be, understood that the figures given represent the 
average limits only, in certain instances the lower limit being 
somewhat below the one given, while the upper limit may be 
higher. Quite distinct from the pitch of a note is its intensity 
or loudness ; this depends upon the amplitude or extent of 
each individual vibration. Although depending upon entirely 
different physical conditions, pitch and intensity are, to a cer- 

(48) 



SOUND. 



49 



tain extent, related, since, as the vibrations increase in num- 
ber, the space traversed during each unit of time by a vibrat- 
ing body must be less. We quite unconsciously prove the 
truth of this statement when we remember that we associate 
loud sounds with high, shrill notes, while the reverse is true 
of tones of the lower portion of the register. In other words 
a given force will produce a more intense sound if it acts upon 
a body in such a manner as to produce molecular vibrations 
rather than vibrations en masse. 

For convenience in recording the various rates of vibration, 
a tuning fork, or other sounding body making sixteen double 
vibrations per second (V. S.), may be called C- 2 ; one making 
double this number of vibrations would be called C- 1 ; the 
two notes differing from each other by an octave. This divi- 
sion of the musical scale, should be remembered as indicating 
that when two musical notes differ from each other by an 
octave the rates of vibration are as two to one. 

In the above we have considered simple vibrations only ; 
but it is to be remembered that a note is seldom heard ab- 
solutely pure, but is accompanied by tones of higher pitch in 
the musical scale. These are called overtones, and they modify 
the character of the fundamental note. These overtones give 
the individuality or quality to the various instruments used in 
an orchestra, and enable us to distinguish whether a given note 
is sounded upon a wind or string instrument. These har- 
monics are much more prominent in the lower divisions of 
the scale, and, as will be seen when we come to speak of the 
functional examination of the ear, are to be borne in mind, 
since by their perception, in place of the fundamental tone 
erroneous deductions may be drawn. 

Sound waves are propagated in any medium surrounding 
a vibrating body at rates varying with the density of the 
medium. The rate of transmission is greater in solids and 
liquids than in gases. In gaseous media the rate of trans- 
mission of sound is in inverse proportion to the density of 
the gas. 

We are now prepared to study the action of the transmit- 
ting mechanism of the ear from a physiological standpoint, 
bearing in mind that this portion of the organ subserves the 
purpose simply of conducting aerial vibrations to the end or- 
gan of the auditory nerve, which analyzes them, so that each 
individual note produces certain specific effects upon the re- 



5 o THE ANATOMY AND PHYSIOLOGY OF THE EAR. 

ceptive centres. We next consider the use of the various 
portions of the conducting mechanism. 

The Auricle. — The auricle, representing the open end of a 
funnel, collects aerial vibrations and directs them into the ex- 
ternal meatus. Its angle of attachment to the skull and the 
variations in contour encountered in different individuals no 
doubt exert slight influences upon sound perception, but this 
fact may be practically disregarded in man, and the auricle 
may be removed without seriously interfering with the func- 
tion of audition. Among the lower animals the auricle plays 
a very important part in the sense of hearing, being movable, 
and capable of assuming various positions from volition or 
reflex action in order better to collect aerial vibrations from 
different points. 

The External Meatus. — The external meatus constitutes 
a tube through which the sonorous impulses are conveyed in- 
ward toward the labyrinth with undiminished intensity. Even 
if this tube is very small in its deep portion, the function of 
audition may be but little impaired, the oscillations in the 
column of air being transmitted with undiminished intensity. 
If the narrowing takes place at the orifice of the meatus, 
acuteness of hearing is much diminished. This condition is 
occasionally found in the aged in whom the tissues have un- 
dergone a certain amount of atrophy, resulting in the collapse 
of the superior w T all of the cartilaginous meatus to such an ex- 
tent that it lies in contact with the inferior wall, completely 
occluding the canal. Occasionally the tragus is abnormally 
developed, and projects backward over the mouth of the 
canal in such a manner as to offer an obstruction to the en- 
trance of the sound waves. This condition also renders the 
hearing less acute. 

As mentioned in a previous chapter, the external auditory 
meatus is not directed horizontally inward, but the cartilagi- 
nous and osseous portions join at an obtuse angle both in 
the horizontal and vertical plane. The cartilaginous canal is 
directed upward, backward, and inward, while the osseous 
portion extends forward, downward, and inward. Where the 
cartilaginous meatus joins the auricle the posterior wall pre- 
sents a deep fossa or depression, and the antero-inferior wall 
of the bony canal close to the membrana tympani exhibits a 
somewhat similar feature. In the cartilaginous canal this 
excavated portion acts with the auricle to collect the waves 



FUNCTION OF THE MEMBRANA TYMPANI. 



51 



of sound and direct them into the meatus, while by the hol- 
lowing out of the antero-inferior.wall of the deeper portion of 
the meatus, the surface presented is parabolic, from which 
reflected waves are directed almost perpendicularly upon the 
drum membrane. Since the meatus is a closed tube it neces- 
sarily possesses a fundamental note, which, according- to 
Gad,* lies in the fourth accentuated octave, representing 
about 4,056 V. S. The effect of the resonant action of the 
canal upon audition is practically inappreciable, its primary 
note lying beyond the limit of the conversational voice. When, 
however, the middle ear is filled with fluid or the drum mem- 
brane is much thickened, the resonant action of the canal 
becomes more marked and "is demonstrable. This is also 
true when the meatus is closed with the ringer or occluded 
by a foreign body, the imprisoned column of air under these 
conditions being set in vibration through the medium of the 
cranial bones. 

The Membrana Tympani. — This structure acts at once as 
a protective septum to the parts lying within the middle ear, 
and as a mechanical device for the reception of sonorous vi- 
brations, which are then transmitted through the agency of 
the ossicular chain to the perilymph, being brought into rela- 
tion with this fluid by the foot plate of the stapes. The ad- 
vantage gained depends upon the relatively large surface 
which the membrana tympani presents in comparison with 
that of the foot plate of the stapes. Any impluse, there- 
fore, acting upon the membrane is transmitted to the stapes, 
at which point its power is much augmented. The drum 
membrane is usually spoken of as a tense fibrous septum, and 
hence should possess a fundamental note peculiar to itself. 
The fact is, however, that, owing to the arrangement of the 
radiating and circular fibres of the lamina propria, its mode 
of attachment to the malleus handle, its oblique position, 
and the relaxed condition of its upper portion — the mem- 
brana flaccida — its fundamental note exercises but an un- 
important influence upon the sense of hearing. It therefore 
transmits notes, varying greatly in pitch, with equal facility 
and without the accentuation of any particular tone, a phe- 
nomenon which would necessarily occur if the membrane 
itself possessed a fundamental note. This impartial transmis- 

* Schwartze, Handb. der Ohrenheilk., Leipzig, 1892, vol. i, p. 338. 



52 THE ANATOMY AM) PHYSIOLOGY OF THE EAR. 

sion of sound waves which impinge upon it, without reference 
to their pitch depends chiefly upon the disposition of the cir- 
cular and radiating fibres in its connective-tissue layer. The 
circular fibres serve to obliterate any resonant action which 
might result from the radiating fibres being thrown into sym- 
pathetic vibration. In the same way the handle of the malleus 
aids in cutting off the overtones, acting as a load upon the vi- 
brating membrane and preventing the accentuation of any 
harmonic. The umbilication of this diaphragm at the umbo 
possesses a mechanical advantage, a force acting upon it being 
increased in intensity as it is transmitted to the malleus handle, 
while the distance traversed by the manubrium is correspond- 
ingly diminished. 

The Ossicular Chain. — The alternate conditions of conden- 
sation and rarefaction brought about by a sounding body are 
transmitted to the labyrinthine structures, after impact against 
the drum membrane, through the ossicular chain. The outer 
member of this chain, the malleus, is attached to the membra- 
na in the manner already described, while the innermost os- 
sicle, the stapes, is in contact with the labyrinthine fluid at 
the oval window. Helmholtz * has shown, from the physical 
laws governing the transmission of sonorous vibrations, as 
the dimensions of the ossicles are so minute in comparison 
with the length of the waves which they transmit, that they 
may be considered as acting en masse — that is, each component 
of the chain acts as a single oscillating particle of infinitesimal 
dimensions, rather than as a solid body the molecules of which 
are in a state of vibration. Viewed in this manner, we have 
to deal with a system of levers through which a force applied 
at the tip of the malleus acts upon the stapes with increased 
energy, but with a corresponding diminution in the space 
traversed in a unit of time. As the result of experiment, the 
same author f found that any force acting upon the tip of the 
manubrium was augmented one and a half times at the incudo- 
stapedial articulation, the extent through which the tip of 
the long process of the incus moved being diminished two 
thirds. 

The preceding remarks regarding the lever-like action of 
the ossicles refers only to forces tending to displace the mal- 
leus inward. It will be remembered that in describing the 

* Op. cit., p. 12. f Op. ci/., p. 46. 



THE FUNCTION OF THE OSSICLES. 53 

ligaments of the tympanum, it was stated that the anterior 
and posterior ligaments constituted the axis band of the mal- 
leus, this bone being supported at their points of insertion 
into its neck, and rotating about an imaginary line passing 
through these points and the tympanic attachments of the 
ligaments as an axis. The peculiar structure of the malleo- 
incudal articulation must also be borne in mind, the articular 
surface of the head of the malleus being in contact with the 
saddle-shaped articular surface of the incus. This articular 
surface is provided with a toothlike projection, so that when- 
ever the manubrium of the malleus moves inward, with a con- 
sequent outward movement of the head, this motion is trans- 
mitted to the incus, and by this ossicle conveyed to the stapes. 
If, however, the tip of the manubrium is drawn outward, the 
toothlike process of the incus no longer engages the mal- 
leus, and the articular surfaces of the ossicles become sepa- 
rated. From this it follows that the stapes is but slightly 
displaced outward under these conditions. The practical 
importance of this will be seen at once when we remember 
how frequently the tympanic cavity is suddenly filled with 
air, either by accident or design, causing an extensive out- 
ward displacement of the membrana tympani. If the articu- 
lar surfaces remained in contact under these conditions the 
effect would be to draw the stapes from the oval win- 
dow. The long arm of the lever above described extends 
from the tip of the manubrium to the short process of the 
incus, while the point of transmission of force to the stapes 
lies in this line at the tip of the long process of the incus. 
The relative lengths of these tw T o arms is in proportion of three 
to two, and the mechanical advantage gained is in the same 
ratio. The movement of the stapes is not directly inward, 
but rather in an oblique plane, the ossicle being rotated about 
its lower and posterior border. Motion in this oblique plane 
results not only from the peculiar position of the oval win- 
dow, but also from the manner in which the incus is fixed to 
the tympanic wall, an inward excursion of the malleus carry- 
ing the long process upward and inward at the same time. 
The obliquity of the plane in which the ossicles are placed 
causes a slight movement forward in addition to the dis- 
placement described, the resultant motion imparted to the 
stapes being a rotation about its posterior and inferior bor- 
ders. The capsular ligament of the malleo-incudal articula- 



54 THE ANATOMY AND PHYSIOLOGY OF THE EAR. 

tion plays an important part in the proper performance of 
the function of this joint. If this ligament is relaxed, the 
articular surface of the malleus, instead of being held closely 
against the corresponding surface of the incus and engaging 
the tooth-shaped process of the articular facet, is drawn 
away from the saddle-shaped articular surface of the incus, 
and causes but slight movement of the ossicle. This condi- 
tion would interfere particularly with the transmission of 
those notes, the wave length of which was relatively con- 
siderable — in other words, the lower notes of the register. 
Too great tension of the capsular ligament interferes with 
free oscillation of the ossicular chain, and consequently with 
the proper transmission of sound waves, particularly those 
of low pitch. High notes, demanding but little displacement 
of the transmitting mechanism, are relatively less interfered 
with by anomalies in the tension of the tympanic ligaments. 

It is interesting to note here the experiments of Politzer * 
regarding the effect produced by notes of various pitch 
upon the excursions of the ossicular chain. It was demon- 
strated that the oscillations of the ossicles were^ less extensive 
for very low notes than for those of the middle portion of 
the scale. When the pitch was very high, however, the am- 
plitude of the ossicular vibrations was again diminished. The 
weighting of the ossicular chain interfered with the trans- 
mission of low-pitched sounds, while the higher ones were 
transmitted practically without interference. As stated 
above, although pitch depends upon the rate of vibration 
and intensity upon the extent of each oscillation, a certain 
relation must exist between them, as is proved by the well- 
known fact to which Gad f calls attention — that of two notes 
sounded with the same intensity, the higher will seem the 
louder. The importance of these circumstances can not be 
overestimated in their bearing upon pathological conditions 
of the conducting apparatus, since the result of clinical ob- 
servation agrees with that of physiological experiment, show- 
ing that in affections of the transmitting mechanism alone, 
the impairment of function occurs first for sounds of very 
low pitch, the upper notes being transmitted with a fair de- 
gree of accuracy. 



* Archiv fur Ohrenheilk., vol. vi, p. 35. 

f Schwartze, Handb. der Ohren., Leipzig, 1892, vol. i, p. 336. 



THE FUNCTION OF THE MUSCLES. 



55 



The Tympanic Muscles. — We have considered above the 
part played by the ossicles alone, without regard to the ac- 
tion of any muscles which might modify their response to 
aerial vibrations. It is necessary, however, to bear in mind 
that, in addition to their ligamentous supports, their action 
is modified by two muscles — the tensor tympani and the 
stapedius. The anatomical characteristics of these have al- 
ready been described. 

The tensor tympani muscle, acting alone, would tend to 
draw the ossicles inward and upward, crowding their articu- 
lar surfaces together and forcing the foot plate of the stapes 
into the oval window. This displacement would of necessity 
render the membrana tympani more tense ; hence the name 
of the muscle, although its action in this direction is of but 
little practical importance. 

The action of the stapedius is antagonistic to that of the 
muscle just described, since by its contraction the stapes is 
drawn out of the oval window by rotating upon the posterior 
margin of the foot plate, with the effect of reducing the ten- 
sion of the labyrinthine fluid. It is probable that one of the 
chief uses of these muscles is to protect the labyrinth from 
the injurious effects of loud sounds, or of the sudden conden- 
sation of air in the meatus from any cause. Since they act in 
opposite directions, they increase the elasticity of the ossicu- 
lar chain, the one guarding the labyrinth from sudden pres- 
sure from without, while the other, by crowding the ossicula 
together, militates against any outward displacement of the 
ossicles from any increase in intratympanic pressure. One 
value of this action is to guard the capsular ligament of 
the malleo-incudal articulation, the fibres of which would 
soon become stretched by repeated condensations of air in 
the tympanic cavity if it were compelled to sustain the entire 
pressure. 

The Muscles of the Eustachian Tube. — In order that the 
membrana tympani may act simply as a transmitter and col- 
lector of aerial vibrations of various lengths, it is essential 
that its normal tension shall not be interfered with. An abso- 
lutely constant tension of this membrane can exist only when 
the atmospheric pressure is the same on either side. To pre- 
serve this equilibrium, the cavity of the tympanum, under nor- 
mal conditions communicates freely with the outer world 
through the Eustachian tube. Owing to the fact that the an- 



56 THE ANATOMY AND PHYSIOLOGY OF THE EAR. 

terior and inferior walls of the membranous portion of the 
passage are formed almost entirely of fibrous tissue, the an- 
tero-posterior walls are in contact, except along the roof, where 
the patency is preserved by the hook-shaped process of the 
cartilaginous plate. Although the physical conditions admit 
of the canal remaining patent in this situation, it is probable 
that the mucous membrane lining the passage is so loosely ap- 
plied, that even here the lumen is practically obliterated 
when the parts are at rest, but that slight changes in pressure 
suffice to render the tube permeable in this portion. This is 
particularly true if the intratympanic pressure is increased, 
as air passes more easily from the tympanum through the 
tube than in the opposite direction. It is comparatively un- 
important whether in certain cases the canal is patent while 
the parts are at rest. Since the aeration of the tympanum is 
accomplished through the action of its attached muscles, the 
part played by them in audition is one of great importance. 
It will be remembered that the tensor palati and the levator 
palati are in relation with the fibro-cartilaginous portion of the 
Eustachian passage, the former arising in part from its ante- 
rior wall, while the latter passes beneath the membranous floor 
along the inferior border of the posterior cartilaginous wall. 
Contraction of these muscles increases the caliber of the tube, 
the tensor drawing the anterior wall and the cartilaginous 
hook forward, while the belly of the levator is augmented in 
volume during contraction and presses the inferior and pos- 
terior walls upward, diminishing the diameter of the canal 
from above downward, but making it more patent. As both of 
these muscles are brought into play during the act of deglu- 
tition, the removal of the air within the middle ear must of 
necessity take place so frequently that the equilibrium of the 
membrana tympani is not disturbed. Temporary variations 
in pressure are undoubtedly compensated for by the action of 
the stapedius and tensor tympani muscles. When, owing to' 
atrophy of the tubal muscles or to obstruction of the lumen of 
the canal from swelling of the lining membrane or from the 
presence of secretion, the passage remains closed for a con- 
siderable period, rarefaction of the air within the tympanum 
is the result. This is brought about by the absorption of air 
into the blood circulating in the lining membrane of the mid- 
dle ear, and by the greater facility with which the air passes 
from the tympanum than in the opposite direction. This re- 



THE FUNCTION OF THE COCHLEA. 



57 



duction in pressure within the middle ear allows the mem- 
brana tympani and attached ossicular chain to be forced in- 
ward by the pressure of the atmosphere, crowding the stapes 
into the oval window. 

The Labyrinth. — The physiology of the labyrinth divides 
itself into an investigation of the function of the vestibule, the 
cochlea and the semicircular canals. 

The Cochlea. — The cochlea is that part of the internal ear 
specialized for the analysis of sonorous vibrations. Through 
its agency each component of any complex sound affects one 
portion of the terminal fibres of the auditory nerve. These 
various stimuli are again combined in the higher nerve centres, 
and are interpreted as characteristic of some particular vibrat- 
ing body, and hence from education enable us to judge of the 
conditions under which they were produced. To effect this 
separation of the complex aerial vibrations the undulations are 
transmitted by the conducting mechanism to a column of fluid, 
the perilymph. Recollecting the anatomy of the parts, it will 
be remembered that the cochlear perilymphatic space is di- 
vided into two channels lying one above the other, communi- 
cating at the apex of the spiral by a narrow passage, the heli- 
cotrema, and separated from each other by a septum which is 
partially osseous and in part membranous. The membranous 
portion incloses between its two layers a channel, triangular 
on cross-section, the membranous cochlea. This canal is an 
elongated blind pouch, and is filled with endolymph in which 
float the ultimate fibres of the auditory nerve. 

The upper cochlear canal communicates with the vestibule, 
while the lower is shut off from the middle ear by the mem- 
brane of the round window. The membranous cochlea termi- 
nates at its superior extremity as a blind sac, while below it 
joins the saccule. The floor of this membranous tube begins 
at the upper part of the round window. The perilymphatic 
space through the aqueductus cochleae communicates with 
the subarachnoid lymph space, while the endolymphatic chan- 
nel, through the aqueductus vestibuli, opens into a sac be- 
tween the layers of the dura mater. The probability of the 
communication between thisdural pouch and the lymph chan- 
nels of the dura has already been discussed. 

Aerial vibrations communicated to the stapes produce a fluid 
wave in the perilymph, each inward excursion of the ossicle 
pushing the column of fluid before it through the scala ves- 



58 THE ANATOMY AND PHYSIOLOGY OF THE EAR. 

tibuli, thence through the hclicotrema, and finally through the 
scala tympani to the round window, the membrane of which 
is pushed outward into the tympanum to compensate for the 
inward motion at the vestibular opening. Since the labyrin- 
thine walls are rigid in every other situation, and from the 
well-known physical law that fluids are incompressible, this 
motion of the perilymph is impossible unless the membrane 
of the fenestra rotunda is elastic. The elastic partition sepa- 
rating these two channels modifies to an extent the course 
taken by this wave in the perilymphatic fluid. This septum, 
consisting of two layers, the space between being rilled with 
fluid of the same density as the perilymph, permits of the 
transmission of the wave motion from the upper to the 
lower channel without necessitating its passage through the 
helicotrema. It is evident that the structures within the 
membranous cochlea must suffer some disturbance of equi- 
librium from the passage of this fluid wave. An impulse 
causing the inward motion of the stapes is communicated 
to the perilymph, which in turn exerts a pressure upon the 
basilar membrane ; this elastic septum yields to the pressure 
in localities varying according to the pitch (or rate of vibra- 
tion) of the particular note sounded. The depression of the 
basilar membrane at any given point causes a change in 
position in the structures resting upon it: these, it will be 
remembered, are the hair-cells and the rods of Corti. It is 
probable that the hair-cells, by the friction of their ciliary pro- 
cesses against the reticular membrane or against the rods of 
Corti, transmit these impulses through the nerve filaments 
which they contain, to the receptive centres of the brain. 
Since the endolymph and perilymph are under equal pressure, 
a fact which has been proved by the investigations of Ost- 
mann* it follows that all vibrations of the perilymph will not 
pass the entire length of the scala vestibuli and through the 
helicotrema before exciting similar waves in the fluid of the 
scala tympani, but will pass directly through the two layers 
of the membranous spiral lamina at any point where the resist- 
ance is less than that which must be overcome by the passage 
of the wave through the helicotrema. The fact that the di- 
ameter of this communicating channel is much less than that 
of either the scala vestibuli or the scala tympani increases the 

* Arch, fur Ohrenheilk, vol. xxxiv, p. 35. 



THE FUNCTION OF THE COCHLEA. 



59 



resistance in this direction and favors the passage of the wave 
through the elastic septum dividing the scalas. The inferior 
lamella of this partition is the membrana basilaris, a tissue 
calculated from its structure to be easily affected by changes 
in pressure. Investigation shows that the parallel fibres of 
the membrane are shortest in the lowest part of the canal, 
and gradually increase in length as the spiral ascends. The 
shorter fibres at the base of the cochlea will yield to the pres- 
sure caused by vibrations of short wave length, or those con- 
cerned in the production of the highest notes of the scale, 
while the slower oscillations of the low notes will travel 
toward the apex of the cochlea before displacing the basilar 
membrane. Anatomical structure and physical laws render 
it probable, therefore, that the lowest turn of the cochlea is 
concerned in the perception of the high notes of the scale, 
while the upper turns serve for the recognition of the deeper 
sounds. These deductions have been confirmed by the phys- 
iological experiments of Baginsky.* 

It seems probable that the basilar membrane is the portion 
of the auditory apparatus designed for the analysis and per- 
ception of musical notes as originally suggested by Hen- 
sen, and that the rods of Corti are not directly concerned in 
this process, as Helmholtz at first believed. 

It is quite probable that these rods serve to damp the vibra- 
tions of the membrana basilaris, and to restrict them to limited 
portions for individual notes. The fibres of the basilar mem- 
brane vary in length from .041 millimetre at the base of the 
cochlea, to .495 millimetre at the apex. In number they vary 
from 13,000 to 20,000. It is evident, therefore, that the per- 
ception of the slightest variation in the rates of vibration can 
theoretically be perceived ; practically, differences of one sixty- 
fourth of a tone can be recognized by the trained ear ; in the 
higher registers, differences of half a vibration per second can 
be distinguished by skilled musicians. 

Nothing has been said in the preceding pages about the 
influence exerted upon the transmission of fluid waves by the 
communication between the endolymphatic and perilym- 
phatic channels and the intracranial lymph spaces. It is 
probable that, owing to the small calibre of the communicat- 
ing canals, the friction of the fluid is so great that their pres- 

*Arch. fur Ohrenheilk, vol. xxiv, p. 54. 



60 THE ANATOMY AND PHYSIOLOGY OF THE EAR. . 

ence is no protection against a sudden increase in tension 
of the labyrinthine fluid, sudden augmentation in pressure 
being compensated for by the elastic septum covering the 
round window. When, however, the increase in pressure 
within the labyrinth is very slow, such as would result from a 
chronic process within the middle ear with the production of 
new connective-tissue elements, crowding the stapes slowly 
into the oval window, it is probable that the equilibrium of 
the labyrinthine fluid would be preserved, in part at least, by 
its passage into the intracranial lymph spaces. 

The perception of musical notes by the agency of the 
cochlea has been considered first on account of its'complex- 
ity ; but it must be remembered that the maculas of the sac- 
cule and utricle and the cristas of the ampullae also contain the 
terminal filaments of the eighth nerve. It is probable that 
noises and perhaps also certain musical sounds are perceived 
here. It would also seem that these structures are particularly 
designed for the reception of vibrations of great amplitude, 
which are interpreted as sound, but that complex sounds are 
not fully analyzed here, although certain variations in pitch 
are recognized. The otoliths are found here and prevent too 
extensive excursions of the ciliae ; their presence in these 
regions alone rather adds weight to the theory that this por- 
tion of the labyrinth is designed for the reception of vibrations 
of considerable amplitude, whether occurring as musical notes 
or following each other irregularly, giving the impression of 
a noise. It seems certain that the ultimate analysis of musical 
tones can only take place in the cochlea ; and hence, from the 
anatomical structure of the parts, the musical notes whose 
perception would be first interfered with in any involvement 
of the labyrinth following a pathological process within the 
tympanum should be those perceived by the basilar mem- 
brane at the lowest part of the cochlea, or that portion close 
to the tympanum. Clinical experience supports this view, 
since in secondary labyrinthine affections we find that de- 
fective perception for the highest notes of the scale is an early 
symptom. 

The Semicircular Canals. — From experiments upon ani- 
mals and from clinical observations it is supposed that the 
semicircular canals are concerned in maintaining the equilib- 
rium of the body, and in recognizing any departure from this 
condition. How much this function contributes to the abil- 



EFFECT OF TYMPANIC CHANGES UPON THE LABYRINTH. 6l 

ity to judge of the location from which a given sound comes 
can not be determined, but it is probable that the position 
which the head assumes, in order that the ear may receive 
the maximum impression of the sounding body, conveys 
to the perceptive centre, through the agency of the semicir- 
cular canals, a certain stimulus which enables the listener to 
locate the approximate position of the sounding body. Re- 
cently Ewald * has attributed to the semicircular canals the 
power of interpreting a sixth special sense, which he denomi- 
nates as the muscular sense or muscle-tonus, holding that the 
perception and maintenance of stable equilibrium are regu- 
lated by the semicircular canals through this special sense. 
Such a claim is difficult to controvert. Any change in muscle- 
tonus must disturb the equilibrium of the body to a certain 
degree, and this in turn would depend for its appreciation 
upon the integrity of the semicircular canals. That these 
portions of the internal ear are the perceptive organs of the 
sixth special sense has not, I think, been conclusively proved. 
The Effect of Changes within the Middle Ear upon the 
Labyrinth. — Since the labyrinthine fluid is separated from the 
tympanic cavity by an elastic membrane at the round window 
and at the oval window by a movable osseous septum, the 
foot-plate of the stapes, it follows that changes in the tension 
of the ossicular chain, due to relaxation or contraction of the 
elastic structures within the middle ear, must cause variations 
of pressure in the labyrinthine fluid. Shortening of the os- 
sicular ligaments and of the tensor tympani muscle will effect 
this change ; or the same result might be brought about by a 
rarefaction of the air within the tympanum, the tension then 
being increased by the atmospheric pressure without. Any 
force acting to displace the foot-plate of the stapes inward, 
causes a similar displacement of the labyrinthine fluid and an 
outward excursion of the membrane at the round window, the 
extent to which this membrane is moved outward depending 
upon its elasticity. Any sudden increase in pressure must be 
compensated for by a corresponding displacement of this 
elastic lamella, since the friction of the fluid against the walls 
of the narrow aqueductus vestibuli and aqueductus cochleae 
would prevent an outward flow in this direction. If the pres- 
sure was maintained for a considerable time, a gradual outflow 

* Physiolog. Untersuch. iiber der Endorg. des Nerv. Octavus. Wiesbaden, 1892. 



62 THE ANATOMY AND PHYSIOLOGY OF .THE EAR. 

of fluid through these channels would undoubtedly take place, 
and the equilibrium would be restored. 

Bezold * has shown that the excursions of the membrane 
of the round window are four times as extensive as those of 
the foot-plate of the stapes, in response to any given force dis- 
placing the latter inward. The area of the stapedial foot-plate 
is greater than that of the membrana tympani secondaria, and 
hence displacements of this latter structure must be corre- 
spondingly more extensive. 

When we come to consider the effect of condensation and 
rarefaction of the air in the tympanic cavity upon the tension 
of the labyrinthine fluid, the mechanism of the malleo-incudal 
articulation must be borne in mind. The effect of increased 
aerial pressure within the tympanic cavity would naturally be 
to force the drum membrane outward. This outward move- 
ment would be participated in by the malleus, and through 
its articulation with the incus would be communicated to this 
ossicle, which in turn would cause an outward movement of 
the stapes, with a reduction of the pressure within the laby- 
rinth. From the peculiar construction of the malleo-incudal 
joint, very extensive outward excursions of the manubrium 
cause a separation of the articular surfaces of the ossicle, and 
the stapes is displaced outward to a comparatively slight de- 
gree as compared with the excursion of the membrana tym- 
pani. The membrana tympani has but little elasticity, owning 
to the peculiar structure of the lamina propria, and after the 
maximum outward displacement has taken place it forms a 
rigid wall. Beyond this, any increased pressure within the 
tympanum, due to the introduction either of air or fluid, 
causes an augmentation of labyrinthine tension, the cavity be- 
ing closed on all sides by rigid walls, with the exception of 
those portions of the inner walls occupied by the oval and 
round windows. This increased pressure acts upon both the 
foot-plate of the stapes and the membrana tympani secondaria, 
since they constitute the areas of least resistance, and their 
inward displacement is opposed only by the normal tension 
of the labyrinthine fluid, which is slightly less than that of the 
normal atmospheric pressure. When the pressure within the 
tympanum is increased by artificial means, or as the result of 
pathological processes, and the cavity has attained its great- 

* Politzer, Lehrbuch der Ohrenheilk., Wien, 1893, p. 54. 



EFFECT OF TYMPANIC CHANGES UPON THE LABYRINTH. 63 

est dimensions by the maximum displacement of the mem- 
brana tympani outward, the next result is a displacement of 
the membrana tympani secondaria and of the foot-plate of the 
stapes inward, increasing- the tension of the perilymph. The 
movement of the stapes toward the vestibule is permitted by 
the separation of the articular surfaces of the malleus and 
incus. The changes in the endolymphatic pressure are the 
same as those in the perilymph. This explains the phenom- 
enon observed frequently after over-inflation of the tym- 
panum, functional examination indicating increased laby- 
rinthine tension in spite of the fact that the membrana tym- 
pani has been restored to its normal position. • 

Politzer* has shown from experiments that aspiration of 
the tympanum — that is, artificially diminishing the aerial 
pressure within it — lowers the labyrinthine pressure instead 
of increasing it. We might suppose at first that this latter 
condition would result on account of the inward displace- 
ment of the ossicular chain from the pressure of the atmos- 
phere. This diminution of labyrinthine tension following 
aspiration of the tympanum is caused by the reduction in pres- 
sure over both the oval and round windows, which more than 
compensates for the inward displacement of the stapes by the 
atmospheric pressure from without. In Politzer's experi- 
ments the pressure within the labyrinth was equal to the 
pressure of the atmosphere, while during life we know that 
it is slightly less than this, and in this condition a moderate 
reduction of tension in the intratympanic air w r ould lower 
labyrinthine tension considerably. As soon as the pressure 
in the middle ear is greatly reduced, labyrinthine tension must 
increase from the extensive inward excursion of the stapes. 
The truth of these conclusions is demonstrated by the effect 
of aspiration and auto-inflation upon the perception of sounds 
of different pitch, as well as the influence which these pro- 
cedures exert upon the conduction of sound through the solid 
media of the skull. It has been proved by Bezold and Sieben- 
mannf that a sudden increase in labyrinthine pressure renders 
the perception of high notes more keen, and increases bone- 
conduction as a rule. The over-inflation of the tympanum has 
been found by the same investigators to effect similar changes. 
Aspiration of the middle ear, on the other hand, according to 

* Op. cit., p. 54. \ Arch, of Otol., vol. xxii, p. 1. 



64 THE ANATOMY AND PHYSIOLOGY OF THE EAR. 

Siebenmann,* usually diminishes bone-conduction — a result 
which we should expect from the reduction of labyrinthine 
pressure. The power of hearing high notes is not particu- 
larly affected by this procedure, on account of the short wave- 
lengths of such sounds and the proximity of the area to the 
middle ear of the cochlea specialized for their reception. If 
the perception of high notes is at all affected, it is rendered 
less keen. 

Increased tension within the labyrinth from displacements 
of the ossicular chain inward — a condition which may be 
brought about from a shortening of the muscular or liga- 
mentous structures attached — is corrected, up to a certain 
point, by a displacement of the membrana tympani secondaria 
in the opposite direction. When the limit of its elasticity is 
reached, the perilymph can no longer vibrate. Up to this 
point, however, the entrance of sound waves into the laby- 
rinth is not prevented. Under certain pathological condi- 
tions the membrane of the round window becomes thickened 
and loses its elasticity. When this occurs even a moderate 
displacement of the stapes inward may be sufficient to render 
vibration of the labyrinthine fluid impossible. This rigidity 
at the round window exerts a greater influence when sudden 
changes in labyrinthine tension occur from extensive and 
sudden displacement of the membrana tympani and ossicular 
chain inward, than where these changes come on gradually. 
When the pressure is slowly increased, a compensatory outflow 
of the labyrinthine fluid through the channels of communica- 
tion with the intracranial lymph spaces is possible ; but sud- 
den augmentation of tension can not be relieved in this way, 
on account of the friction of the column of fluid against the 
walls of the capillary passages through which it is forced. 
This explains why we find so great a reduction of the upper 
tone-limit in sudden closure of the Eustachian tube, while 
proliferative changes within the middle ear cause secondary 
labyrinthine involvement only after a long period — in the one 
case, pressure being increased suddenly, in the other case, 
gradually. 

The individual parts of the auditory tract having been 
considered, a few words may not be out of place in review- 
ing its action as a whole. 

* Loc. cit. 



REACTION OF AUDITORY NERVE TO STIMULI. 65 

Under ordinary conditions, sonorous impulses, projected 
through the air, reach the end-organ of the nerve specialized 
for sound perception by the transmutation of aerial waves of 
condensation and rarefaction, through the agency of the tym- 
panic structures, into waves of similar character in the laby- 
rinthine fluid. These waves in turn impress the terminal 
filaments of the auditory nerve in a specific manner. Nor- 
mally, then, sounds are best heard through the air; it is pos- 
sible, however, for the fluid within the labyrinth to be set in 
vibration through the medium of the cranial bones, resulting 
in the phenomenon of sound perception. When the laby- 
rinth is intact, musical notes are interpreted with a fair de- 
gree of accuracy when they reach the labyrinth by bone- 
conduction — that is, when the vibrating body is brought in 
contact with the bones of the head. There are reasons for 
believing that even when the labyrinth is seriously affected 
the auditory nerve itself may react to vibrations which are 
conveyed to it through the bones of the skull. An explana- 
tion of this fact is offered by Gad,* who advances the hy- 
pothesis that under normal conditions the auditory nerve- 
trunk not only transmits stimuli resulting from the analysis 
of complex sounds by the labyrinth, but is also excited by 
the impulses of the vibrating body acting as a mechanical 
stimulus. This last effect will not be prevented by the de- 
struction of the portion of the nerve designed for the analysis 
of sound, the impression received affecting the sensorium as 
a whole rather than as distinct individual notes. The in- 
creased electric irritability of the nerve, so often found where 
the labyrinth has been destroyed in the course of physio- 
logical experiments, rather adds weight to this view. Even 
where the labyrinth is entirely separated from the auditory 
nerve-trunk, the excitation of the nerve by sounding bodies 
of different pitch would probably produce different effects 
upon the perceptive centres, although the exact differences 
could not be defined by the subject. In this hypothesis the 
auditory nerve follows the laws which govern the reaction of 
all sensory and motor nerves to stimuli of various kinds, 
whether they be thermal, mechanical, or electrical. The 
weak point of this theory lies in the fact that in physiological 
experiments one can never be certain that the cochlea has 



* Schwartze, Handb. der Ohren., 1892, vol. i, p. 348. 
6 



66 THE ANATOMY AND PHYSIOLOGY OF THE EAR. 

been entirely destroyed, while in cases of exfoliation of the 
cochlea in man, as the result of disease, the process has usu- 
ally been unilateral, and the part played by the unaffected 
ear can not be excluded with certainty. Corradi* has demon- 
strated by experiment, that in the porpoise destruction of 
both cochleae causes complete deafness ; but it is not safe to 
say that the same result will follow in the human species. It 
is enough for practical purposes to remember that the exact 
interpretation of sound is only possible when the cochlea is 
intact ; while it is probable that the stimulation of the nerve- 
trunk itself may be effected by a sounding body or other 
stimulus, even if the end-organ has been destroyed. 

The Concerted Action of the Auditory Apparatus. — It is 
still a question of dispute as to the exact influence exerted by 
the auditory organ of one side upon that of the opposite side 
of the body. Unquestionably the hearing is most delicate 
when both organs are in perfect condition. If one ear is 
occluded by the finger or obstructed from any pathological 
process, sound perception becomes less acute, and the power 
to distinguish the location of a sounding body is correspond- 
ingly interfered with. No doubt the correlation of the organs 
of the opposite sides depends largely upon the decussation of 
the fibres of the cochlear nerve in the brain, as described in the 
pages devoted to anatomy of the auditory nerve. It must be 
remembered, however, that if perfect audition presupposes the 
anatomical perfection of both organs, a condition might exist 
in which the transmission of sonorous waves by the apparatus 
of one side would be so incorrect as to interfere with the 
perception of those conveyed through the auditory organ of 
the opposite side. Cases are met with in which the hearing 
can be improved by completely occluding one ear artificially, 
thus excluding the sound waves from it. That in the normal 
subject binaural audition is better than monaural is explained, 
according to Urbantschitsch,f by the fact that the stimulation 
of the peripheral organ of the auditory nerve on one side, ren- 
ders the perceptive centre on the corresponding side, and which 
receives fibres from the opposite ear, more susceptible to the 
action of the sound waves. This excitation of the receptive 
centre renders it responsive to slight stimuli reaching it 



* Archiv f r Ohrenheilk, vol. xxxii, p. i. 

f Lehrb. der Ohren., Wien, 1890, p. 416. Arch, fur Ohrenheilk., vol. xxxv, p. 1. 



REFLEX PHENOMENA. 67 

through the opposite ear. In support of this argument, we 
recall the fact that the acuteness of audition upon one side 
for any given sound will be increased if the organ of the 
opposite side is at the same time brought under the influence 
of sound waves of a different character ; thus, for instance, a 
watch may be more clearly perceived in the right ear if a 
vibrating tuning fork is held close to the meatus of the left. 
In this way Urbantschitsch explains the phenomenon of para- 
cousis Willisii, the action of loud sounds serving to stimulate 
the receptive centres, after which relatively feeble stimuli, as 
vibrations of small amplitude, may be perceived. Binaural 
audition, then, would owe its acuteness to the exciting action 
of one auditory centre upon the other. Politzer,* on the 
other hand, believes that the greater acuteness of binaural 
audition depends upon the fact that it represents the effect 
of an impulse acting upon a greater area, and hence pro- 
ducing a more marked impression, upon purely mechanical 
principles. This latter suggestion seems the more simple, and 
yet a close observation of the phenomena produced by vari- 
ous pathological processes reveals the existence of such an 
intimate interdependence between the organs of the opposite 
sides, that it is hard to believe that this association does not 
play an important part under normal as well as under patho- 
logical conditions. 

Reflex Phenomena. — We have spoken at length of the ac- 
tion of one auditory organ upon the other, but it must not be 
forgotten that the nucleus of the eighth nerve of either side 
communicates not only with its fellow, but is intimately asso- 
ciated with the central nuclei of the other cranial nerves, as 
well as with various spinal centres. The function of the ear 
is affected not only by the action of sonorous waves, but also 
reflexly by the action of various stimuli upon other centres 
with which the auditory is in intimate relation. Conversely, 
any excitation of the sound-perceiving apparatus may effect 
psychical, sensory, or motor changes in remote regions of 
the body. The phenomenon, often observed, of starting at 
any sudden sound undoubtedly depends upon reflex action ; 
the association between particular sounds various colors and 
is an example of the curious effect produced on account of 
the communicating fibres between the acoustic and visual 

* Op. cit., p. 516. 



68 THE ANATOMY AND PHYSIOLOGY OF THE EAR. 

centres. On the other hand, the power of audition may be 
perverted or annulled reflexly, by a pathological condition 
affecting fibres of a nerve trunk, the centres of which are in- 
timately associated with the auditory nerve nuclei. 

Phenomena dependent upon Circulatory Changes. — 
Through the intimate relation which exists between the 
blood-vessels of the labyrinth, the tympanum, the higher nerve 
centres presiding over audition and the cervical sympathetic, 
it is plain that circulatory changes must exert an important in- 
fluence upon the function of audition, perverting or impairing 
it, either indirectly by inducing vascular changes within the 
tympanum or directly by causing circulatory changes in the 
end organ or ganglia of the eighth nerve. This fact is to be 
particularly remembered in considering certain subjective 
symptoms frequently complained of, experience showing that 
correction of vaso-motor tone often relieves the manifesta- 
tions. On the other hand, disturbances in the blood supply 
may depend upon actual organic changes in the vessels or in 
the blood itself. It is evident, especially in the consideration 
of subjective phenomena, that there exists a broad field for 
speculation, not only in diagnosis, but also in the selection 
of appropriate therapeutic measures. 

Secondary Phenomena. — In this same line lie those dis- 
turbances, both objective and subjective, which depend upon 
a morbid process in some other organ of the body. Here we 
may mention the symptoms met with in connection with con- 
gestive derangements of the larger viscera, and relieved only 
by remedies appropriate for the correction of the exciting 
cause. Disturbance of the auditory centres in the female is 
not uncommon in uterine and ovarian disorders. 

The relation between ocular and aural derangements has 
lately been emphasized by Oliver and Cleveland ; * many of 
these must be reflex in character. The reflex disturbances of 
the most importance are those occurring in the domain of 
the trigeminal nerve. This nerve supplies many filaments to 
the external and middle ear, and in the latter location, it will 
be remembered, a close association exists between the cranial 
and sympathetic nerves. As a result, any morbid condition 
which involves parts supplied by the trigeminus may, by 

* Burnett's System of Diseases of the Ear, Nose, and Throat. Philadelphia, 1893, 
vol. i, p. 516. 



SECONDARY PHENOMENA. 69 

involvement of the nerve elements which they contain, so 
interfere with the trophic supply of some portion of the ear 
as to cause not only functional disturbances but even organic 
changes in the tissues. 

In this connection the influence of dental caries is the most 
familiar instance, it having been proved that decayed teeth 
may produce not only a functional disturbance of the organ 
of hearing, but also an acute inflammation of the tympanum. 
Most interesting, also, is the close relation between corre- 
sponding parts of the auditory apparatus of the opposite sides 
of the body. Here, no doubt, the phenomena observed de- 
pend upon reflex action through the sympathetic and cranial 
nerves and, in many cases, upon the decussation of the audi- 
tory fibres within the brain. The effect is at first reflex in 
character, but later the result of degeneration or atrophy. 
The so-called " sympathy " between the ear of one side with 
that of its fellow was recognized by Kramer,* Wharton Jones,f 
and many other early writers. Recently Urbantschitsch £ has 
written extensively upon the subject. 

The effect of increased labyrinthine tension from rigidity 
and displacement inward of the ossicular chain upon the func- 
tion of the opposite ear is made prominent by Weber- Liel * 
and by Cholewa.|| The writer A has also called attention to the 
fact, especially in cases operated upon for chronic inflamma- 
tory conditions of the tympanum, that the function of the op- 
posite ear has been improved after operation. Gelle () is in- 
clined to look upon the temporary impairment of function 
observed when the meatus is closed with the finger, while at 
the same time a vibrating body is held close to the unob- 
structed meatus, as due to a reflex contraction of the ten- 
sor tympani muscle upon the non-occluded side, and makes 
use of the experiment to prove the integrity of the upper cer- 
vical nerves, these being comprised in the reflex chain. It 



* Ohrenheilk., 1836, p. 145. 

f Frank's Ohrenheilk., 1845, p. 133. 

X Arch, fur Ohrenheilk, 1893, vol. xxxv, p. 1. 

* Monatsschr. fur Ohrenheilk, 1874, No. 6. 
1 Arch, of Otol., vol. xix, p. 151. 

A N. Y. Eye and Ear Infirmary Reports, vol. i, p. 50, vol. ii, p, 62. Wood's 
Reference Handbook of the Medical Sciences. New York, 1893. (Supplement.) 
Art. " Middle Ear Operations," 

Q Arch, fur Ohrenheilk, vol. xxviii, p. 58. 



; THE ANATOMY AND PHYSIOLOGY OF THE EAR. 

seems to me that the manifestation can be better accounted 
for by the direct effect of the pressure upon the end organ of 
the acoustic nerve, and the transmission of the stimulus to the 
perceptive centres of both sides. 

Like other nerves, the auditory trunk may be rendered 
less capable of transmitting impulses either by overuse or 
disuse, and for the same reasons the higher receptive cen- 
tres may cease to functionate properly. Thus, if the ear is 
subjected for a long time to the action of a single sound, this 
particular note will, after a time, cease to be perceived as 
readily as at the beginning of the experiment, although per- 
ception for other notes of the scale will be unaffected. If, on 
the other hand, the nerve is allowed to remain inactive for a 
long period, as where serious obstruction to sound conduc- 
tion has rendered the ear of little practical use, it is found 
that even after the removal of the obstruction and the resto- 
ration of the conducting mechanism to a normal condition, 
the function of the ear is imperfect from the fact that the 
nerve has been so long at rest that it is not able to subserve 
the purpose for which it was designed. On the other hand, 
after the nerve trunk and receptive centres have been once 
excited, they react more readily to stimuli and require less 
energy to maintain them in a condition of irritability than 
would be required to arouse them from a state of repose. It 
is frequently found, in testing the hearing with a watch or 
other similar instrument, that the hearing distance will be 
greater if the sounding body is first held close to the ear and 
then gradually withdrawn until it is no longer heard, than 
if the experiment is reversed : the sounding body being 
gradually carried toward the ear from a point at which it is 
not perceived until a position is reached where it is distinctly 
audible. This means simply that the auditory nerve having 
once been excited, reacts to a stimulus of less intensity than 
that required for its initial excitation. On account of the 
decussation of the auditory fibres in the medulla, it is also 
true that the functional activity of the ear on one side may 
be increased by stimuli directed to the opposite ear. 

Urbantschitsch * explains this upon the hypothesis that the 
excitation of the cortical centre of one side by means of sono- 
rous vibrations acting upon the opposite ear renders sound per- 

* Lehrb. der Ohren., 1890, p. 416. 



HYPERESTHESIA AND PARESTHESIA. 



71 



ception more acute in the other ear on account of the decussa- 
tion of the auditory fibres, through which the cortical centre 
receives fibres from the labyrinth of the corresponding and 
opposite sides. Stimulation of the opposite labyrinth increases 
the irritability of the centre and causes it to respond to a 
slighter stimulus, whether this is received through the cor- 
responding or opposite end organ. I have already suggested 
such an influence in explaining the improvement observed in 
the organ not operated upon in cases subjected to operative 
procedures. Urbantschitsch * has so extended the field of 
possible utility in this direction that it is of the utmost im- 
portance to bear the relation in mind on account of its thera- 
peutic usefulness. This writer urges that this stimulation of 
the perceptive centres may follow the action of sonorous 
vibrations, even if the ear acted upon is so defective as to be 
incapable of transmitting impulses to the degree necessary for 
actual sound perception on the part of the patient. In other 
words, when the organ of one side has been rendered entirely 
useless by sclerotic changes in the conducting mechanism, he 
deems it warrantable to relieve this physical abnormality be- 
fore the influence which it may exert upon the opposite side 
can be decided. 

We have discussed the effect upon the receptive centres 
of overstimulation by sonorous waves, and also the result fol- 
lowing a long period of inactivity. It must be remembered 
that, like other nerve centres, the auditory nuclei and fibres 
react to other stimuli than those for which they were espe- 
cially designed. Pressure upon the terminal filaments, trunk, 
or centre of the eighth nerve excites, perverts, or destroys its 
function. Slightly increased pressure upon the terminal fila- 
ments, from congestion of the labyrinth, may render the nerve 
exceedingly sensitive, and may give rise to subjective noises 
(parsesthesise). One of the most curious effects observed 
from this increased activity is the persistence of auditory 
impressions ; for example, when a certain piece of music is 
played upon the piano, the hyperaesthetic centre may retain 
a mental picture of this for a long period, and the individual 
be annoyed for hours afterward by the subjective impression 
of hearing the selection continually, exactly as it has been 
played originally. In the same manner it is not an uncom- 

* Arch, fiir Ohrenheilk., voL xxxv, p. I. 



72 THE ANATOMY AND PHYSIOLOGY OF THE EAR. 

mon experience for patients to aver that they hear the tick 
of a watch even after the sound has ceased, the impression 
once received being- maintained for a long- interval. It is of 
great importance to bear this in mind in testing the hearing 
with any instrument, such as the watch or acoumeter, where 
the same sound is repeated, as otherwise erroneous conclu- 
sions will be reached. 

Too great stimulation, either on account of the sudden 
condensation of air in the auditory canal, as when a loud ex- 
plosion takes place close to the ear, or by loud sounds con- 
tinued for a considerable period, may cause great impairment 
of hearing for varying intervals of time, the sudden increase 
in pressure, on the one hand, or the prolonged and intense 
excitation on the other, completely destroying either tran- 
siently or permanently the function of the delicate perceptive 
portions of the auditory system. Familiar examples of these 
effects are observed among artillerymen, in whom a tempo- 
rary impairment of hearing is not uncommon, after exercise 
with the great guns of the battery. Among soldiers who 
have been under heavy fire for many days, the prolonged 
and excessive excitation of the receptive centre or of the 
terminal filaments of the nerve has been known to produce 
permanent results, although usually the impairment has been 
but temporary. 



CHAPTER III. 

PHYSICAL EXAMINATION. 

Preliminary Observations. — Before describing in detail the 
instruments needed for the proper examination of the ear, let 
us recall briefly the topography of the region. 

The external meatus is made up of two tubes, joined at an 
angle in both the vertical and horizontal planes, re-entrant 
downward and forward. The fundus of this canal constitutes 
the drum membrane, and is continuous with its cutaneous lin- 
ing. The length of the entire passage, measured from its out- 
ermost point — that is, from the tragus to the drum membrane 
— is thirty-six millimetres, or about one inch and a half. This 
should be remembered as de- 
termining the proper length of 
instruments to be manipulated 
in the meatus. It should also be 
borne in mind that of this inch 
and a half, a little less than one 
inch of the tube is cartilaginous 
and a little over half an inch 
osseous. The general direction 
of the cartilaginous tube is up- 
ward, backward, and inward, 
while that of the bony conduit 
is downward, forward, and in- 
ward. For the satisfactory in- 
spection of the deeper parts, it 
is evident that the axes of these 
canals must be made as nearly as 
possible coincident ; as the out- 
er portion is movable, traction 
upon the auricle upward and 
backward tends to bring the axes into the same straight line. 

Fig. 25 illustrates the position assumed by the parts in the 
adult when the auricle is drawn upward, backward, and out- 

(73) 




Fig. 25. — Pen-drawing from adult 
specimen, showing the result of 
drawing the auricle upward and 
backward. The axes of the bony 
and cartilaginous meatus are made 
coincident, permitttng an inspec- 
tion of the drum membrane (actual 
size). 



74 



PHYSICAL KXAMINATION. 



ward. It will be seen that the cartilaginous and bony meatus 
form practically a straight canal, the angle marking their 
junction having been obliterated by traction in the directions 
named. 

In infants the superior and inferior walls of the meatus are 
in contact and must be separated before the membrana tym- 
pani can be seen. This is due to the absence of the bony 
meatus at birth. As the superior wall of the fibro-cartilaginous 
tube is attached to the squama, the separation of the walls can 
be effected only by traction downward and backward, the in- 
ferior wall being pulled away, so to speak, from the superior 
wall. Fig. 26 clearly demonstrates this fact, and it should be 




Fig. 26. — Drawing from specimen at 
birth. Traction must be made down- 
ward and backward to expose the 
membrana tympani (actual size). 



Fig. 27. — Drawing from specimen from 
child, aged five years. The develop- 
ment of the bony meatus has separated 
the superior and inferior walls, but 
traction downward will still expose the 
membrana tympani most completely 
(actual size). 



remembered that in young children the auricle should be 
drawn outward, backward, and downward in making a specu- 
lum examination. 

In children several years old the development of the bony 
canal has effected this separation of the walls of the deep 
meatus, but even in these cases the membrana tympani is 
more clearly seen if the auricle is drawn slightly downward 
rather than upward. Fig. 27, drawn from a specimen taken 
from a child of five, makes this clear. 

Since the cartilaginous meatus alone is dilatable, the field 
of inspection can not be increased in size by crowding a 



PRELIMINARY OBSERVATIONS. 



75 



dilating instrument beyond the osseo-cartilaginous junction. 
On the other hand, since such a procedure fixes the two por- 
tions immovably at their angle of union, the field of inspection 
must be considerably narrowed. Moreover, an instrument of 
greater external dimensions than the calibre of the fibro- 
cartilaginous tube will crowd the soft parts inward toward 
the fibro-osseous junction, and this mass will obstruct the view 
of the deeper parts. 

The fundus of the canal is formed by the drum membrane. 
This is obliquely placed both in the horizontal and vertical 
planes of the long axis of the meatus. The inferior margin 
of the membrane forms an angle with the horizontal plane of 
from thirty to forty degrees, while the anterior margin makes 
an angle of about one hundred degrees with the vertical me- 
dian antero-posterior plane of the body. From the confor- 
mation of the meatus at its inner extremity, the angles which 
the membrana tympani makes with the posterior and superior 
walls are somewhat greater than those made with the vertical 
and horizontal planes. In other words, the drum membrane 
is really a continuation of the superior wall of the meatus, 
and, to a less extent, of the posterior. From this it follows 
that the superior and posterior margins of the membrane are 
nearer the orifice of the meatus than the inferior and anterior. 
In the young infant the membrana tympani lies in the plane 
of the surface of the squama. To be brought into view the 
operator must direct his glance upward toward the superior 
wall of the canal. 

In investigating diseases of the ear it has been the custom 
to lay special emphasis upon the appearance of the drum 
membrane as observed upon ocular inspection, and to form 
opinions as to the prognosis of any malady largely from the 
information thus obtained. It should be remembered that in 
most cases we are consulted for an impairment or perversion 
of the function of the organ, and hence, while inspection of 
the visible parts is very important and should be made with 
all the skill attainable, it is also equally important to conduct 
a systematic functional examination, for the discovery of the 
location, extent, and nature of the pathological condition re- 
sponsible for the symptoms complained of by the patient, and 
to determine as well to what extent the power of sound per- 
ception is interfered with, the normal ear being taken as the 
standard in conducting such tests. In this manner we can 



76 PHYSICAL EXAMINATION. 

more intelligibly estimate the amount of damage done, and, 
combining the information obtained both from functional and 
physical examination, we arrive at an opinion of greater value 
than that obtained by ocular inspection merely. 

To properly examine the parts so situated as to be open 
to ocular inspection it is necessary to secure a proper illumi- 
nation of the region. From the depth and sinuous course of 
the auditory meatus, examination by direct illumination has 
never been as successful as when the light has been reflected 
upon the parts by means of a mirror. 

The Source of Light. — We have to consider, in the first 
place, the source of light. If sunlight could always be de- 
pended upon it would, no doubt, be the best source of illumi- 
nation for an otoscopic examination. The direct ravs of the 
sun, when reflected into the ear, produce such a brilliant illu- 
mination of the parts that detail is obscured. Diffuse day- 
light or light from a white cloud forms a very perfect source 
of illumination, but naturally can not always be obtained. I 
am in the habit, therefore, of advising students to accustom 
themselves to the various appearances as seen by artificial 
light. An ordinary oil lamp, if fitted with a duplex or other 
powerful burner, is an excellent source of illumination. The 
same can be said of an Argand gas-burner; even a common 
candle emits sufficient light to enable the surgeon to make a 
perfect examination, and to perform any operation within the 
canal which an emergency might demand. At least one of 
these means of artificial illumination can be found in any 
house, and familiarity with normal and pathological appear- 
ances when viewed by such light can not fail to be of great 
service to the otologist, who is often obliged to make an 
examination at the bedside. For convenience in making an 
examination at the bedside, as an adequate source of illumina- 
tion may not always be obtainable without delay, or may de- 
mand the aid of an assistant to permit of a proper examination 
without moving the patient, it is well for the examiner to be 
provided for such an emergency. For this purpose use may 
be made of the device shown in Fig. 28, which consists of a 
clamp which may be fastened to a table, chair, the frame of 
the bedstead, or any other firm object in the room, as may 
be convenient. This clamp carries a jointed rod, which sup- 
ports a short arm for holding an ordinary candle. For city 
practice the ordinary fish-tail gas-burner may be substituted 



THE SOURCE OF LIGHT. 



77 



in place of the candle, the burner being- attached to a small 
metal band which fits into the candle-holder. This burner is 
connected with a gas fixture in the room by means of a flexi- 




Fig. 28 — Author's portable illuminating apparatus. In the figure the candle and 
electric lamp are in position ; the gas-burner is shown in the detached drawing 
on the left. 



;8 PHYSICAL EXAMINATION. 

ble pipe attached to it. This apparatus enables one to secure 
a fairly efficient source of illumination and to place the light 
in exactly the position from which he may make the examina- 
tion with greatest comfort to the patient and to himself, and 
renders the entire procedure less laborious and correspond- 
ingly more exact. The entire apparatus occupies but little 
space in the instrument bag, and greatly facilitates bedside ex- 
amination. A small electric lamp suitable for operative work 
can also be attached to the vertical rod, while a light shelf for 
supporting an oil lamp can be fitted upon the arm carrying 
the candle, if the examiner prefers this source of illumination. 

The different appearance of the parts viewed by artificial 
light as compared with the picture seen when diffuse day- 
light is employed, depends upon the fact that all artificial 
sources of illumination contain a preponderance of yellow rays, 
and hence the reds and yellows are slightly exaggerated in 
the otoscopic picture. No mistake need be made if this fact 
is borne in mind, even by an observer accustomed to the 
use of white light. 

Since the introduction of electricity as an illuminating 
agent its employment in otological work has become quite 
common. The rays which the incandescent lamp yields are 
almost colorless, and any desired intensity can be obtained. 
The reflected image of the luminous carbon band sometimes 
gives rise to annoyance — a difficulty which can be obviated by 
the employment of a system of mirrors, the effect of which is 
to obliterate the image entirely and yield only a diffuse white 
light, which the surgeon can then reflect into the ear by means 
of the mirror. A manifest objection to the electric light lies 
in the fact that it is not always obtainable, although this is in 
a measure overcome by the introduction of portable storage 
batteries. Its greatest advantage is that when ether anaesthesia 
is required, there is no danger of ignition of the vapor, since 
the luminous carbon is completely inclosed. 

As electricity, even when carefully handled, is a somewhat 
capricious agent, it is well for the operator to be supplied with 
an additional source of illumination in every case, so that in 
the event of the electric apparatus failing, some other efficient 
means may be at hand. 

The Reflecting Mirror. — It was formerly the practice in 
examining the ear by means of reflected light, to direct the 
rays into the canal by a plane or concave mirror fixed upon a 



THE REFLECTIiNG MIRROR. 



79 



short handle (Fig. 29), and held in one hand, while the other 
hand grasped the auricle and supported the speculum in the 
proper position. Obviously the most 
correct information is obtainable by 
the simultaneous inspection and ma- 
nipulation of the parts ; it is necessary, 
therefore, that the surgeon have one 
hand free for the use of a delicate 
probe. At the present day the reflect- 
ing mirror is usually worn upon the 
forehead, and the polished surface is 
concave, thus bringing the luminous 
rays to a focus in front of the mirror. 
The light will be most intense at the 
principal focus of the instrument, and 
the best definition will be obtained at 
a point just within this ; hence the focal 
distance of the mirror should be such 
that when the parts are perfectly il- 
luminated, the eye may be as near as 
possible to the region to be examined, 
w T hile at the same time sufficient space 
intervenes between the ear of the pa- 
tient and the surface of the mirror for 
the manipulation of such instruments 

as it may be necessary to use. It is seldom practicable for 
the eye of the observer to be less than eight or ten inches 
from the deepest part of the region under inspection. In 
selecting a mirror, therefore, the focal distance should not 
be less than seven inches, nor more than eleven inches. This 
fact should be borne in mind in choosing the instrument, and 
can be most easily ascertained by noting the distance between 
the mirror and the hand when the rays of light are brought 
to a focus upon the palm. Where artificial light is used, the 
rays are divergent, and hence the conjugate focus for such 
rays will be more remote than the principal focus, which is 
the point to which the parallel rays are converged. It is also 
advisable to be provided with a mirror which will serve for 
an examination of the ear, and of the nose and naso-pharynx as 
well. For the inspection of the regions last named the focal 
length of the mirror should be slightly greater than of one 
which is suitable for otological work alone. A mirror of 




Fig. 29. — Hand mirror. 



8o 



PHYSICAL EXAMINATION. 




from eight to ten inches focal length for divergent rays is well 
adapted to general use, it being only necessary to move the 
source of light a little nearer the mirror when the throat or 

m >se is to be exam- 
ined. 

If the illuminat- 
ing- apparatus ispro- 
vided with a con- 
densing lens Which 
renders the rays 
parallel, the focal 
distance as deter- 
mined by sunlight 
will be correct ; 
otherwise a mir- 
ror of shorter focal 
length for parallel 
rays than that given 
above should be se- 
lected. It is easy 
to determine wheth- 
er the mirror is per- 
fectly ground by observing the image of the gas flame or 
candle at the focal point of the mirror ; if the rays are 
thrown upon the hand or upon a sheet of w T hite paper, we 
should secure a sharply defined image of the particular flame 
w T ith which we are experimenting ; if the edges of the image 
are blurred, the mirror is practically useless for delicate 
work. The size of the mirror is also important; those sold 
in the shops are usually perforated in the centre, the mir- 
ror being worn in such manner that the perforation will lie 
over one or the other eye, thus bringing the visual ray of 
the examiner through the centre of the cone of reflected light. 
When the mirror is worn in this way its diameter should not 
be greater than three and a half inches ; a diameter of two and 
a half inches is fully sufficient. 

Certain observers prefer to wear the mirror upon the fore- 
head, in which case the eye of the examiner does not look 
directly through the cone of light, the rays illuminating the 
parts to be inspected being reflected from them at an acute 
angle to the eye of the observer. When this method of exam- 
ination is employed the diameter of the mirror is immaterial, 



Fig. 30. — Reflecting mirror, adapted for use both as a 
head or hand mirror. 



THE REFLECTING MIRROR. 



81 



but nothing is gained by increasing the area of the reflecting 
surface. Still other observers wear the mirror in such way 
that its superior border is below the orbits, the mirror lying 
directly over the nose, and the examiner looks over the top of 
the glass rather than through its centre. It certainly seems 
more simple to perfectly illuminate the parts by the first 
method of examination, since the position which permits of 
the most perfect inspection gives at the same time the most 
perfect illumination. This, however, is a matter of practice, 
and after becoming accustomed to one method of examina- 
tion it is unnecessary to change, equally good work being 
possible by all methods. It should be emphasized, however, 
that the beginner will do well to employ one method con- 
stantly, and not attempt to be- 
come expert at several. 

Sometimes the source of light 




Fig. 31. — Head mirror, with nasal support. 



Fig. 32. — Head mirror. 



is an incandescent lamp worn upon the head of the exam- 
iner, the instrument being provided with lenses which focus 
the rays upon the parts to be inspected ; such a light is worn 
either upon the forehead (Fig. 33) or lower down upon the 
bridge of the nose. Considerable practice is necessary in 
order to become expert in the use of such a device for pur- 
poses of examination, even after one is familiar with the use 
of the head mirror. 

The objection to a mirror of large diameter lies in the 
fact that when the central perforation is used, the border of 
the mirror lying close to the uncovered eye interferes with 

7 



82 



PHYSICAL EXAMINATION. 



the perfect relaxation of the organ. This constitutes a source 
of eye strain, and after the instrument has been worn for sev- 
eral hours considerable discomfort is occasioned. 

Regarding- binocular inspection of the parts, it is mani- 
festly impossible to view so small an object as the membrana 
tympani, with both eyes through a narrow canal, since the 
length of the canal and the small diameter of the entrance of 
the meatus would render it necessary to have the examiner so 
far away from the object to be examined, that the exact struc- 
ture could be seen no longer. The eye not in use should be 
completely relaxed, and the beginner should under no cir- 
cumstances close it, as the muscular exertion which this en- 
tails becomes a source of great discomfort after a compara- 
tively short time. When the examiner is accustomed to 
make use of the central perforation in the mirror, and desires 
to use an incandescent light, this may be arranged upon 
a standard as shown in Fig. 28, the rays from the lamp 
being reflected into the canal in the same manner as when 
any other source of illumination is employed. The focal 
length of the condensing lens under such circumstances is a 

matter of great im- 
portance ; its focal 
distance should be 
such that the rays 
are rendered parallel 
or slightly divergent 
when they strike the 
mirror. If conver- 
gent rays fall upon 
the reflecting surface, 
the result will be that 
the light will be 
brought to a focus 
at a point within the 
true focal distance of 
the mirror, beyond 
which point they will 
again diverge, and 
the illumination of the parts will be imperfect unless the head 
is brought so close to the ear as to render instrumentation 
within the canal impossible. Some prefer to wear the in- 
candescent light upon the forehead (Fig. 33), dispensing with 




Fig. 33. — Electric lamp worn upon the forehead. 



AURAL SPECULA. 83 

the head mirror entirely, the rays being brought to a focus 
upon the deeper parts within the canal by means of a series 
of lenses of proper curvature. Those accustomed to the use 
of the head mirror upon the forehead will find no difficulty 
in this method of examination. Where one habitually uses 
the central perforation in the mirror, the instrument being 
worn over one eye, considerable practice is necessary to be- 
come expert in using the incandescent light directly. This is, 
in a measure, overcome by making use of a device consisting 
of a head mirror, to the periphery of which a small incandes- 
cent light is attached ; a metallic reflector and shade surround 
the lamp and direct the luminous rays upon the surface of the 
mirror, after which they are thrown into the canal in the 
same manner as when a stationary lamp is used. I repeat 
here, that all electric apparatus is apt to be capricious, and 
that it is well in operating outside of a hospital, where all 
appliances can be obtained at a few moments' notice, to be 
provided with another source of light in case of accident to 
the incandescent lamp. For my own use, the portable stand- 
ard shown in Fig. 28 is so arranged as to support both the 
incandescent lamp and an ordinary gas-burner, the latter 
being connected with any convenient gas fixture in the 
room, and care being taken to have it in perfect working 
order before any operation is begun. The knowledge that 
an accident to the battery or lamp will not prove a source 
of annoyance is a great mental satisfaction to the operator. 

Aural Specula. — In order to inspect the deeper parts of 
the meatus, the membrana tympani, and the tympanic cavity, 
it is necessary to separate the walls of the cartilaginous canal, 
and to overcome the irregularities, at the same time changing 
the axis of this tube to correspond with that of the osseous 
meatus. This latter object is attained by traction upon the 
auricle in a direction upward, backward, and outward, while 
the walls of the canal are at the same time separated and 
maintained in a position by the aural speculum. These in- 
struments may be made of hard rubber, metal, or even of 
stiff paper, and vary in shape. Individual choice plays a 
prominent part in the selection of the particular form of 
instrument to be employed, but certain rules, applicable to all 
instruments of this character, must be borne in mind. The 
material of which the speculum is made must be as thin as 
possible, in order to secure the maximum field of inspection ; 



84 PHYSICAL EXAMINATION. 

many of the instruments sold are so thick and heavy that, 
although the outside diameter is comparatively large, the 
calibre is very small, and when the meatus is narrow an 
instrument that can be introduced with comfort to the pa- 
tient yields but a small area for inspection. Care should 
be taken that the end of the instrument inserted into the 
meatus has a perfectly smooth margin, as any irregularity 
of outline is sure to cause discomfort to the patient, and in 
children, to begin with an unfortunate accident of this kind 
may render an examination almost impossible. The length 
of the speculum is also a matter to demand attention. It 
is essential that the instrument shall project no farther be- 
vond the entrance of the meatus than is necessary to per- 
mit of its being firmly held, since the difficulty of examina- 
tion becomes greater when the observer is obliged to direct 
the light through a long, narrow passage to illuminate a 
small area at its extremity, and at the same time recognize 
minute variations in the condition of the parts. Under the 
most favorable circumstances the meatus itself presents ob- 
stacles which render an exact interpretation of the conditions 
observed very difficult, and to increase the length of the 
passage is to add greatly to these. The speculum should 
be just long enough to allow the surgeon to hold it firmly 
when in position and no longer. It is also important that 
the portion of the tube introduced into the canal should 
taper slightly, since the deeper parts are less distensible than 
those more superficially placed, and if the speculum fills the 
canal completely it can not be tilted in different directions, 



ooo 





Fig. 34. — Politzer's hard rubber Fig. 35. — Wilde's aural 

auial speculum. speculum. 

so as to bring the various portions of the fundus into view. 
The exact shape is unimportant ; some examiners prefer an 
instrument the orifice of which is circular in outline, while 
others advise that it be oval, corresponding in form to the 
lumen of the canal as seen in cross section. The instrument 



AURAL SPECULA. 



85 



bearing the name of Wilde is conical, and the orifice circular, 
while in Gruber's speculum the tube is oval on cross section, 
and instead of being- conical is somewhat funnel-shaped. This 
last feature is observed in the instruments of Troelsch, Bou- 
cheron, Toynbee, Politzer, and others. Many prefer a single 
instrument which can be adjusted to the lumen of any canal 
by means of a set screw, the device resembling in construe- 



poo 





Fig. 36. — Gruber's aural specu- 
lum. 



Fig. 37. — Toynbee's aural specula. 
(The instruments are too long, and 
the cut is introduced to show this.) 



tion the bivalve speculum of the rhinologist. In some in- 
stances it is advantageous to have one wall of the tube cut 
away for a certain distance in order that the meatus may be 
inspected after the instrument has been inserted. This end is 
best accomplished by employing a wire speculum, the walls 
of the meatus being separated by the elasticity of the mate- 
rial of which it is constructed. In an emergency a very serv- 
iceable speculum can be made with a piece of stiff note paper, 
twisted into the form of an elongated cone, the free edges of 
the paper being secured by a pin, a stitch, or by mucilage. 
This cone is then cut off at such a distance from the apex as 
will allow it to be easily inserted into the meatus, while in 
the other direction it is so cut as to reduce it to a proper 
length. Such an improvised instrument answers perfectly well 
not only for diagnosis, but also for operative purposes. In 
fact, I frequently use them in preference to metal specula, even 
when the latter are at hand. Their chief advantage is their 
cleanliness, the same cone never being used a second time. 

Whatever form of speculum may be chosen, attention to 
the above points will result in the selection of a serviceable 
instrument. Exact shape is immaterial, as constant use will 
soon enable the surgeon to become expert with any one of the 
various varieties. One possible advantage possessed by the 
funnel-shaped instruments, in which the outer opening is very 
wide, is that the examiner can more easily direct the light 
into the speculum than when the smaller instrument of Wilde 



86 PHYSICAL EXAMINATION. 

is used. Whether the interior of the instrument is polished 
or blackened also depends upon individual preference. The 
contrast of the black background may be an advantage, but a 
certain amount of brilliancy of illumination is sacrificed. 

It is necessary to be provided with specula of various sizes, 
and at least three are necessary to meet the differences in 
diameter of the orifice of the meatus, while five or six sizes 
are still more advantageous. The proper diameter, accord- 
ing to Richards,* of the smaller end of each speculum in a 
set of five of the Wilde pattern is given below, and will be 
found valuable; 7 mm., 6 mm., 4-66 mm., 4 mm., 3-5 mm. 

Being provided with a satisfactory source of light, a 
proper head mirror, and a suitable speculum, the next step 
will be the technique of the examination. 

The Technique of Examination (Fig. 38). — The patient and 
examiner may both be seated, a position which I decidedly 
prefer, or both may stand, or the patient may sit while the phy- 
sician remains standing. The patient is best seated in a high- 
backed chair, in an attitude which can be maintained for some 
time without discomfort, the head resting against the back of 
the chair, the affected ear being turned toward the examiner. 
The surgeon, either sitting or standing, should occupy a posi- 
tion to the right of the patient rather than directly facing the 
affected side. Sitting or standing, this latter position must 
be an awkward one, and in the event of the examiner prefer- 
ring to remain seated, necessitates the separation of his knees 
widely, so that the chair of the patient is between them. 
This posture is not only uncomfortable, but for obvious rea- 
sons undesirable. Moreover, the operator is not able to fol- 
low any sudden motion of the patient's head when seated in 
this manner, since he is working at arm's length. When the 
other position is employed, a slight motion of the arm enables 
the operator to so follow any sudden movement which the 
patient may make on account of fear or pain that the exact- 
ness of the manipulation is in no way disturbed. 

The light should be placed, preferably, on the left of the 
examiner, and. slightly above the horizontal plane passing 
through the ear to be examined. In this manner any ma- 
nipulation of instruments with the right hand will not inter- 
fere w r ith the rays passing from the lamp to the mirror. 

* Burnett's System of Diseases of the Ear, Nose, and Throat, 1893, vol. i, p. 105. 



TECHNIQUE OF EXAMINATION. 87 

The patient, surgeon, and source of light being satisfac- 
torily arranged, it should be the invariable rule to examine 
the auricle, the entrance of the meatus, and the cartilaginous 
canal to as great a depth as possible before the speculum is 
introduced, as the speculum may conceal some pathological 
condition at the very entrance of the meatus unless this rule 
is followed. In order to- examine the cartilaginous canal and 
to prepare for the insertion of the speculum, the auricle should 
be grasped firmly but lightly at its upper and posterior mar- 
gin between the third and fourth fingers of the left hand, and 




Fig. 38. — The ocular inspection of the membrana tympani, showing the position of 
the patient, the surgeon, the source of light, and the manner of holding the 
speculum. 

traction should be made upward, backward, and outward. In 
examining the right ear the hand lies behind the auricle ; in 
examining the left ear it lies above and anterior to it. In this 
manner a fairly good view of the external portion of the meatus 
is obtained, and any irregularities in size and shape may be 
noted as well as any deviation from the usual direction. The 
information thus derived enables the investigator to select a 
speculum of appropriate size, which should be grasped lightly 
between the thumb and index finger of the left hand, warmed 
over the lamp, and then introduced into the canal as lightly 
as possible. To effect this the operator holds the speculum 
between the thumb and index finger, grasping the auricle, 



88 PHYSICAL EXAMINATION. 

as before, between the third and fourth fingers of the left 
hand. While the auricle is drawn upward, outward, and 
backward, the dilating instrument is gently introduced into 
the meatus, is advanced gradually by rotation upon its long 
axis, it being rolled, so to speak, between the thumb and index 
finger, while at the same time it is pushed inward. Care should 
be taken not to pass the instrument beyond the cartilagi- 
nous canal, since this is not only painful, but interferes with 
the mobility of the outer portion of the meatus, and hence 
limits the area exposed for inspection. The speculum must 
be of such a size that the walls of the canal are simply sepa- 
rated by it and not stretched, as this interferes with the mo- 
bility of the membranous portion of the canal and prevents 
it being so manipulated as to make its axis coincide with 
that of the bony meatus. When the speculum is too large 
the soft parts are so crowded in front of it that the full lumen 
of the speculum is not available and the field is narrowed in 
consequence. 

The speculum having been properly inserted, the observer 
should first bring that part of the superior wall of the canal 
into view which lies just beyond the inner extremity of the 
speculum. This is done by carrying the thumb and index 
finger which hold the instrument downward, thus tilting the 
inner extremity upward. Having recognized the superior 
wall of the meatus, the anterior, inferior, and posterior walls 
are successively brought into view by causing the outer end 
of the speculum to describe a circle in the direction named, 
the fixed point being the inner extremity of the instrument. 
This manipulation is accomplished by a slight movement of 
the thumb and finger which grasp the outer end of the specu- 
lum, the digits being alternately flexed and then gradually 
extended until the extremity of the instrument has described 
a complete circle. In conducting this manipulation each 
wall of the meatus should be inspected throughout its entire 
extent, from the inner end of the speculum to where it joins 
the tympanic ring. 

Attention should be paid during this procedure to the fol- 
lowing points regarding the canal : Whether it is free through- 
out its entire length, or partially or completely obstructed. 
If the lumen is encroached upon, information should be ob- 
tained as to the nature of the obstruction, whether it be a for- 
eign body accidentally or intentionally introduced, or whether 



TECHNIQUE OF EXAMINATION. 



89 



it is made up of a mass of impacted secretion, whose source 
is the ceruminous glands of the meatus, or of epithelial debris, 
the result of an inflammatory process, or of a parasitic growth 
which has proliferated in this locality. On the other hand, 
the deeper portion of the canal may be filled with fluid, either 
pus, serum, mucus, or blood. Again, the lumen of the canal 
may be encroached upon only over a certain circumscribed 
area, in which case the probe determines the density of the 
obstruction — whether it is hard or soft, tender or anaesthetic, 
whether invested with normal epithelium or presenting a de- 
nuded surface. Its location should always be carefully noted, 
whether it is situated in the deeper portion of the canal or 
near the orifice. In other cases the canal may be narrowed 
uniformly throughout its entire extent. Here the density of 
the walls as determined by the probe is of service, as well as 
the appearance of the outer surface. None of these more evi- 
dent abnormal conditions existing, the observer should in all 
cases note the condition of the integument lining the canal, 
determining whether it is dry and desquamating in places, or 
moist and reddened, or covered here and there with masses of 
dry secretion forming crusts upon the walls. Having critic- 
ally observed these different physical conditions, the superior 
wall of the meatus should be followed inward, the angle of 
the speculum being gradually changed so as to bring the 
deeper portions into view until this aspect of the canal merges 
into the membrana flaccida. The outer end of the speculum 
being still further elevated, the eye next recognizes the epi- 
dermal covering of the membrana tympani and follows this 
until it passes quite abruptly into the inferior wall of the 
meatus. An examination in this manner — the superior wall 
being followed across the fundus of the meatus until the eye 
looks upon the inferior wall, and the posterior wall traced 
until it merges without a break into the anterior — demonstrates 
with certainty that the membrana tympani is present, and, if 
no solution in continuity has been observed, intact. This is 
the most satisfactory method of demonstrating that the mem- 
brana tympani is present and unbroken throughout its entire 
extent. Whenever there is a solution of continuity this regu- 
lar outline must be broken. In some cases, where the mem- 
brane is almost completely destroyed and is replaced by cica- 
tricial tissue which applies itself closely to the internal wall of 
the tympanum, a mistake may be made ; this is scarcely pos- 



9 o PHYSICAL EXAMINATION. 

sible, however, if an exhaustive examination is made, each 
wall being- followed until it merges into the one directly op- 
posite. When the membrana is extensively destroyed, as 
mentioned above, we find usually at some point along the 
posterior wall that the fundus of the canal is not continuous 
with this wall, but that there is a solution of continuity at the 
inner extremity, the epidermis not passing directly from the 
posterior wall of the canal to the promontory, but that a cer- 
tain space is left between these two regions, the width of the 
hiatus being easily recognized by the practiced eye. I have 
given this as one of the early steps in conducting the examina- 
tion, since the observer more readily analyzes appearances 
met with if the question of presence or almost complete de- 
struction of the drum membrane has been settled before other 
points are considered. 

We must next recognize certain landmarks at the fundus 
of the canal, which under normal conditions is occupied by 
the membrana tympani (Fig. 39). As the superior wall is fol- 
lowed inward, there will be seen just below the centre of the 
line marking its inner termination, a prominent projection, 
white or grayish white in color, having the appearance as 
though the soft parts covering it were pushed outward into 
the lumen of the canal by some firm body beneath. This pro- 
jection is the short process of the malleus, and its position 
changes but little, no matter how much the entire ossicle may 
be displaced by rotation about the axis from alterations in 
tension of the intratympanic ligaments and muscles. More- 
over, this portion of the ossicle is richly supplied with nutrient 
vessels, and even when there is extensive caries of the tym- 
panic walls and of the ossicular chain, it usually escapes dis- 
integration. Under normal conditions the short process of 
the malleus appears as a prominent point, about the size of a 
pinhead, varying in color from a chalky white to a grayish 
white or even pinkish white. Extending downward and some- 
what backward from this point, through the middle of the 
membrane as far as its centre, the handle of the malleus is 
recognized. This process tapers gradually as it passes down- 
ward. At its lower extremity it is flattened slightly from 
without inward, and appears a little broader than just above 
its termination. The shaft of the malleus is slightly curvi- 
linear in outline, the convexity being toward the meatus in 
the upper two thirds, while at the lower third it is directed 



THE MEMBRANA TYMPANI. 9I 

inward and somewhat backward, lying more nearly in the 
plane of the membrane. The outline of the shaft, under normal 
conditions, appears somewhat darker than the surrounding 
membrane, its presence offering an obstruction to the rays of 
light illuminating the fundus of the canal. The outline of the 
shaft is not infrequently slightly pinkish instead of white, and 
occasionally one or two blood vessels may be recognized trav- 
ersing the membrane close to the manubrium and parallel to 
it. This is particularly true if the speculum has remained in 
the canal for some time, and depends upon the venous con- 
gestion incident to the presence of the foreign body. The 
flattened termination of the manubrium at the centre of the 
membrane is known as the umbo. Under normal conditions 
the eye perceives a bright triangular area upon the surface of 
the membrane, extending from the umbo downward and for- 
ward to the periphery, the apex of the triangle lying at the 
umbo, while the base of the triangle does not extend to the 
periphery, but fades away gradually before it reaches this 
line. It is evident that if we imagine the malleus handle to 
be prolonged to the periphery of the membrane, this struc- 
ture will be divided into two portions — one in front and 
the other behind the line, the posterior portion being the 
larger. If a horizontal line is drawn through the umbo to the 
anterior and posterior walls of the canal, these two segments 
will be again divided into two. For convenience in locating 
pathological appearances we conceive the drum membrane to 
be so divided, the segments being named the superior anterior, 
inferior anterior, inferior posterior, and superior posterior 
quadrants according to their situation. From the short pro- 
cess of the malleus two bands are observed, 
one running backward, the other in the op- 
posite direction, to the periphery of the 
membrane. Of these, the posterior is the 
longer, the anterior being just barely seen 
under normal conditions owing to the prox- 
imity of the short process of the malleus to p IG< 39 _The normal 
the upper anterior extremity of the tym- membrana tympani 

. * . J .... (somewhat diagram- 

panic ring, and because of the obliquity matic). 

of the plane in which the membrane lies. 

These bands are called the anterior and posterior folds of the 

membrane. They are caused by the difference in tension 

between the membrana tensa below and the membrana flac- 




02 PHYSICAL EXAMINATION. 

cida above. These bands arc sometimes very well marked, 
while in other instances they are not distinct. 

Between the short process of the malleus and the superior 
wall of the meatus the membrana tympani presents a distinctly 
triangular form, the apex of the triangle lying at the short 
process, from which point the sides of the triangle diverge 
until they are lost in the superior wall of the canal, into 
which they pass without any distinct line of demarcation. The 
sides of the triangle are clearly marked by a thickening along 
the lateral boundaries of this triangular area. This upper 
portion of the drum membrane is the membrana flaccida, or 
Shrapnell's membrane, and the fibres which form the sides 
of the triangle are known as Prussak's fibres. It will be re- 
membered that the tympanic ring is w r anting at Shrapnell's 
membrane, the curvilinear outline being completed by the 
free border of the outer lamella of the squamous plate of the 
temporal bone, which fills up the gap between the anterior 
and posterior limbs of the annulus. The name of Rivinian 
fissure or segment has been given to this dehiscence in the 
annulus tympanicus. It is also to be borne in mind that the 
lamina propria of the drum membrane is wanting over this 
area, the septum being completed by the tegumentary lining 
of the canal which passes downward over the Rivinian fis- 
sure, its epithelial layer being continued over the surface of 
the membrana tympani. 

Having determined that the membrana tympani is intact, 
or, if any solution of continuity exists, the extent and location 
of the defect having been made out, the observer should next 
note the following physical properties of the membrana or of 
its remaining portion : i. The color. 2. The lustre. 3. The 
structure. 4. The position. 

The Color. — The normal membrane is of a pearly-white 
appearance, with a slightly bluish tinge over the entire mem- 
brana tensa ; above the folds the parts may have a faint pink- 
ish hue, even when in a healthy condition. 

The Lustre. — The recognition of variations in the lustre of 
the drum membrane constitutes one of the most valuable aids 
in the diagnosis of aural affections. Normally the parts pos- 
sess a peculiar sheen which can not be described in words, 
but is easily recognized when once seen. The triangular light 
spot has already been spoken of, and its persistence or ab- 
sence, the variations in shape, position, and extent, and the 



THE MEMBRANA TYMPANI. 93 

presence of one or more bright points or light reflexes in other 
parts of the membrane, all furnish valuable information. The 
lustre may be diminished or may be entirely wanting, this 
latter condition always indicating a necrosis of the superficial 
epithelium. 

The Structure. — Under this term we consider the devia- 
tions from the normal appearance resulting from changes in 
the various layers of the part under examination. In health 
the membrana vibrans is of uniform texture throughout, ex- 
cept at the periphery and at the umbo, in which localities it 
is somewhat thickened and consequently less translucent than 
elsewhere. The eye is also able to make out indistinctly the 
circular and radiating fibres as they cross one another, giving 
an appearance suggestive of a finely woven fabric. Under 
pathological conditions the membrana propria may undergo 
hypertrophy in places, in which case the uniformity of tex- 
tural appearance will be lost and the affected areas will appear 
less translucent than the surrounding portion. The same ef- 
fect is produced, but in a more marked degree, by calcareous 
deposits in the fibrous layer. These appear as opaque, lustre- 
less white areas, with well-defined outlines. On the other hand, 
as the result of pressure, cicatrization after loss of substance, 
etc., the fibrous layer may be very thin or even wanting in 
certain localities. Here the membrane will be transparent, and 
through the thin septum the underlying structures within the 
tympanum may be easily recognized. The membrana flaccida, 
containing no lamina propria, does not exhibit the peculiar 
woven appearance characteristic of the larger segment of the 
drum membrane ; its appearance is similar to that of the skin 
lining the adjacent part of the bony meatus, except that it is 
more delicate in structure. Owing to pathological changes 
it may become transparent and parchmentlike, or its thick- 
ness may be greatly increased. 

The Position. — Normally, the drum membrane is inclined 
both in the horizontal and vertical planes. In addition to this 
it is drawn inward at the umbo on account of its intimate con- 
nection with the manubrium mallei. The inclination in two 
planes, together with the umbilication at the centre, gives rise 
to the light reflex, the rays illuminating this area alone be- 
ing reflected directly back to the eye of the observer, without 
previously impinging upon the walls of the canal. Another 
result of the umbilication is to give to each segment of the 



94 PHYSICAL EXAMINATION. 

membrana a slightly convex appearance when viewed from 
the canal, which is most marked in the upper and posterior 
quadrants. In the young- child the inclination of the mem- 
brane in the horizontal plane, as viewed through the meatus, 
appears more pronounced than in adult life. This greater in- 
clination is more apparent than real, depending upon the spe- 
cial conformation of the parts at birth. At this period, it will 
be remembered, the superior and inferior walls of the meatus 
are in contact, the superior wall lying upon the external sur- 
face of the squama while the bony meatus does not exist, be- 
ing represented by a canal of fibrous tissue, especially well 
developed along the inferior wall. 

Having reviewed the appearance of the membrane under 
normal conditions, we are now prepared to recognize varia- 
tions caused by morbid processes. As the upper and posterior 
part is nearest the eye of the observer, and as this is the most 
extensive segment of the membrane, displacement of the entire 
membrane outward in this region is more apparent than else- 
where. If displacement be excessive the bulged posterior por- 
tion may overhang the anterior segment and partially or com- 
pletely obscure it. Sometimes the effect is to obliterate in this 
region the line of demarcation between the canal wall and the 
drum membrane, giving to the fundus a narrow appearance. 
On the other hand, marked retraction obliterates the normal 
prominence of the upper and posterior segment and exagger- 
ates the inclination of the upper part of the membrane in the 
horizontal plane, at the same time causing the inferior segment 
to appear more nearly perpendicular to the inferior Avail of the 
canal. It also tends to exaggerate the apparent width of the 
drum membrane on account of the greater depth of the tym- 
panum above and behind, which allows the membrana to move 
inward for a considerable distance, thus bringing the anterior 
segment into view. As seen through the speculum, this in- 
crease in the transverse diameter, especially of the inferior 
segment, is exceedingly well marked. The most valuable in- 
dication of retraction, however, is afforded by a careful inspec- 
tion of the malleus handle. This prominent and easily recog- 
nizable landmark appears foreshortened in direct proportion 
to the degree of retraction, provided adhesions between it and 
the inner tympanic wall do not exist, and prevent it from as- 
suming the usual position which it occupies when the pressure 
within the tympanic cavity is lowered. Another evidence of 



OBSTACLES TO EXAMINATION. 95 

extreme retraction is the prominence of the curved margin of 
the tympanic ring, which can frequently be traced throughout 
its entire circumference when the membrane is displaced in- 
ward to a marked degree. It sometimes happens, owing 
to the presence of adhesions, that the handle of the malleus is 
not foreshortened; then the displacement of the segments of 
the drum membrane in front and behind the manubrium, to- 
gether with the marked prominence of the annulus and the 
ease with which the intratympanic structures are seen, enable 
the observer to interpret the condition correctly. When the 
malleus handle is firmly bound down and the air within the 
tympanic cavity is rarefied, the anterior and posterior seg- 
ments of the drum membrane collapse, and the manubrium 
appears as a prominent ridge between the sunken areas. In 
front, behind, and below this ridge there are deep pits or fossae, 
where the more elastic membrane has been forced inward by 
the pressure of the air until it has impinged upon the inner 
tympanic wall. In children this condition is very prone to 
exist where adenoid vegetations are present. The appearance 
is not infrequently a source of error in diagnosis, being mis- 
taken for a total destruction of the membrana vibrans and 
a subsequent dermoid transformation of the inner tympanic 
wall. 

Obstacles to the Examination. — The description given of 
the technique of the inspection of the ear by means of re- 
flected light, presupposes that an unimpeded view has been 
possible ; occasionally, however, obstacles are encountered 
which render the inspection of the deeper parts difficult 
Here we may mention the presence of fine hairs in the meatus 
preventing a perfect illumination of the membrana tympani. 
In such an event the examiner, after the insertion of the 
speculum, will find it advisable to apply a little vaseline or 
wax to the hairy area by means of a cotton-tipped probe ; by 
this procedure the hairs are made to adhere closely to the 
wall of the canal, and are prevented from interfering with 
the examination. If the orifice of the meatus is exceedingly 
narrow, either as the result of congenital malformation, cica- 
tricial contraction, or an acute circumscribed inflammatory 
process, the examiner will do well to use an exceedingly 
small speculum. By tilting the instrument at various angles 
it will be possible to inspect the deeper parts over successive 
small areas until the necessary information has been obtained. 



96 PHYSICAL EXAMINATION. 

This is wiser than to attempt to use a large instrument which 
tits the canal closely, in the hope of obtaining a more ex- 
tended field of view. 

The prominence of the anteroinferior wall occasionally 
offers an obstacle to perfect inspection of the deeper parts ; 
but here again the small speculum will enable the observer 
to see a more extended surface than a larger instrument, 
provided the auricle is drawn upward and backward suffi- 
ciently to permit the illumination of the parts beyond the 
obstructing canal wall. In the same manner, if the orifice of 
the meatus is almost closed, as the result of an acute inflam- 
matory process, and the parts are excessively tender, it is pos- 
sible, by exercising a little care, to introduce a small specu- 
lum beyond the inflamed area, and to obtain a view of the 
deep parts. It is to be remembered that no bony meatus 
exists at birth, and the membrana tympani lies superficially 
and in nearly the same plane as the superior wall of the canal, 
which is closely attached to the outer surface of the squama; 
hence, to obtain a clear view of the membrane, the auricle 
must be drawn downward and backward instead of upward 
and backward, as in the examination in an adult (Fig. 26). 

In addition to what has already been said concerning the 
recognition of the various normal and pathological condi- 
tions, it is necessary to call attention to special portions de- 
manding particular investigation ; these are the periphery 
of the membrane, and that area lying above the level of 
the short process, the membrana flaccida. It is quite pos- 
sible to recognize all the conditions enumerated in the pre- 
ceding pages and yet to overlook a small perforation, unless 
the examiner, as a final step, inspects the entire outline of 
the annulus, following with the speculum the line of attach- 
ment of the membrane throughout its entire circumference. 
Again, that region situated above the short process of the 
malleus and the folds of the membrane demands careful at- 
tention, since it covers the articulation between the malleus 
and the incus, and that portion of the tympanum where the 
mucous lining is thrown into numerous folds as it passes 
from the bony walls of the cavity over the intratympanic 
ossicles and ligaments. It is not uncommon to find a minute 
perforation through the membrana flaccida, which might pass 
unrecognized unless special attention had been directed to 
the inspection of this locality. It should be borne in mind in 



TYMPANIC TOPOGRAPHY. gy 

this connection that we occasionally meet with a minute open- 
ing-, just above the short process of the malleus. This was 
formerly supposed to be occasioned by the incomplete closure 
of the Rivinian segment. A small opening at this point is, 
according to Randall,* due to a pathological process, and 
there is no foundation for considering it a result of imperfect 
development. Under all circumstances both ears should be 
examined, although the patient may complain of but one. 
The importance of this is evident if the reader will recall 
the remarks already made in the chapter on physiology, con- 
cerning the interdependence of one organ upon that of the 
opposite side. It is also important, since any slight anomaly 
in the direction of the canal or in the position of the mem- 
brana tympani will probably exist on both sides, and a source 
of error in the interpretation of appearances found in the 
affected organ will thus be removed. 

At this point we should consider the relation between the 
contents of the tympanum and the various quadrants of the 
tympanic membrane. 

Fig. 12 represents the intratympanic structures and the 
inner wall of the middle ear, the ossicles lying in their nor- 
mal position. A portion of the inferior and posterior wall of 
the canal is shown. The membrana tympani, with the excep- 
tion of a small crescentic portion posteriorly, has been re- 
moved and the contents of each quadrant can be easily made 
out. 

In the supero-posterior quadrant the long process of the 
incus is seen descending in a direction parallel to the manu- 
brium mallei, lying behind it and at a deeper level in the 
tympanic cavity. The articulation of this process with the 
head of the stapes is also seen, together with the posterior 
crus of this latter ossicle, which passes upward and inward 
until it is lost in the oval niche. From the head of the stapes 
a delicate fibrous band is observed, which extends directly 
backward until it is lost from view behind the margin of the 
tvmpanic ring. This is the tendon of the stapedius muscle. 
The tip of the descending crus of the incus (and hence the 
incudo-stapedial articulation) may frequently lie at a consid- 
erable distance below the level of the short process of the 
malleus. On the other hand, and especially as the result of 

* Trans Am. Otol. Society, 1894. 



98 PHYSICAL EXAMINATION. 

a pathological condition, this process of the incus may run 
almost horizontally inward, the processus lenticularis being 
hidden behind the supero-posterior margin of the bony ring. 
In such an event the stapes itself and the stapedius tendon are 
out of the range of vision. Another situation frequently oc- 
cupied by this process of the incus is close to and just behind 
the posterior margin of the bony ring. It passes downward 
in a direction parallel to the posterior limb of the annulus, and 
is brought into view if the patient's head is turned away from 
the examiner, permitting the illuminating rays to pass behind 
the projecting margin of the ring. This position of the incus 
is usually the result of contraction of the stapedius muscle 
or of shortening of its tendon. Search with a delicate probe 
reveals the location of the crus of the incus, the instrument 
being easily hooked about it and drawing it into view. If 
firmly fixed, the division of the stapedius tendon or of dense 
adhesions passing backward from the posterior crus of the 
stapes releases it and brings it into the field of vision. The 
upper and posterior quadrant, since it contains structures so 
important to the function of audition, should always be closely 
examined, whether the membrana tympani is intact or par- 
tially destroyed. Frequently the attenuation of the mem- 
brana in this locality, either from cicatrization or atrophy, 
enables the observer to recognize the above-mentioned parts 
through it. This is particularly so when there is consider- 
able retraction of the drum membrane, which then applies 
itself closely to the structures beneath. 

Below the incudo-stapedial articulation in the lower part 
of the supero-posterior quadrant, and encroaching to a greater 
or less extent upon the postero-inferior quadrant, is seen a 
deep niche the posterior boundary of which is hidden by the 
margin of the annulus tympanicus, while the anterior mar- 
gin forms the postero-inferior boundary of the promontory. 
At this line the inner tympanic wall bends at almost a right 
angle, and the plane of the niche is directed backward and 
downward. The depression formed by this sudden bend is 
the niche of the round window. Sometimes it lies entirely 
behind the margin of the ring and out of the field of vision. 
The portion of the tympanic wall occupying the middle of 
the field of inspection is the promontory. It covers the first 
turn of the cochlea, and exhibits a convex surface which en- 
croaches to a varying extent upon the the cavity of the tym- 




TYMPANIC TOPOGRAPHY. 99 

panum. When this portion of the wall is unusually convex, 
and the niche of the round window can be seen, the pro- 
jecting- mass will occasionally be mistaken for an exostosis 
unless the possibility of its anomalous prominence is borne 
in mind. The region corresponding to the anteroinferior 
quadrant presents nothing demanding special notice, except 
that the tympanic opening of the Eustachian tube may en- 
croach upon its upper part. In the majority of cases the 
tympanic orifice of the tube lies in the upper anterior quad- 
rant and may be entirely concealed by the anterior border of 
the tympanic ring. 

When the membrana vibrans is absent it is possible to 
pass a delicate probe, bent at a right angle at the tip, upward 
into the vault of the tympanum, both in front and behind the 
short process of the malleus, the angular portion disappear- 
ing completely in the upper 
tympanic space. Traction 
outward causes the bent part 

Of the probe to press upon FlG 40 ._ M iddle ear probe. 

the inner extremity of the su- 
perior wall of the canal, and the instrument can not be re- 
moved by traction directly outward, it being necessary first 
to disengage its tympanic extremity from the inner margin 
of the superior wall of the meatus. 

As the result of caries, the superior wall of the meatus 
close to the tympanum may be destroyed, bringing into view 
a portion of the head of the malleus and the adjacent part of 
the incus, or, where the ossicles have been destroyed or 
displaced, the upper part of the inner tympanic Avail lies ex- 
posed. We then see distinctly the pelvis ovalis, and just 
above this the wall of the aquaeductus Fallopii arching over 
it. If this last structure has been involved in the carious 
process, impact of the probe may cause twitching of the 
facial muscles, owing to mechanical irritation of the seventh 
nerve. 

Naturally, in inspecting the tympanic cavity where the 
membrana tympani has been destroyed as the result of dis. 
ease, or where a flap has been reflected for the purpose of 
exploration, the parts which can be brought into view will 
largely depend both upon the position in which the head of 
the patient is placed and upon the correct manipulation of the 
speculum, so that areas hidden from the direct line of vision 



IOO PHYSICAL EXAMINATION. 

by the overhanging margins of the inner extremity of the 
canal may be illuminated by rays from the head mirror. 

Botey * has advised the use of small mirrors, which are to 
be introduced into the tympanic cavity for the purpose of in- 
specting the parts lying beyond the direct line of vision ; but 
the procedure has met with little success. Blake f suggested 
the same method long ago, and made a practical application 
of it to determine the attachment of a growth springing from 
the inner extremity of the superior wall of the canal. 

In the preceding pages we have spoken of the physical 
characteristics revealed by ocular inspection. The reader is 
not to understand, however, that the eye alone is to be used ; 
a delicate probe is of great service in settling a doubtful 
appearance, and the value of its use can not be too strongly 
advocated. Where it seems unadvisable to use a metal in- 
strument for fear of injuring the delicate structures, a very 
satisfactory substitute is found in the use of what may be 
termed a cotton probe, constructed as follows : A small bit of 
cotton is wound tightly about the extremity of a delicate cot- 
ton holder (Fig. 41) in such a manner that the cotton shall 
project for about a quarter of an inch beyond the end of the 



Fig. 41. — Cotton holder. 



shaft, it being wound so tightly as to offer considerable resist- 
ance upon pressure, and constituting really a prolongation of 
the probe. This cotton tip can be bent at any desired angle, 
and is firm enough to retain its shape, and yet not so firm as to 
injure the delicate structures encountered. It is less disagree- 
able to the patient than a metallic instrument, while it is of 
equal service to the examiner. An instrument constructed in 
this manner can be introduced through a small perforation in 
the membrana tympani, or into a sinus in front of or behind the 
short process, and be carried into the upper part of the cavity. 
Tactile impressions resulting from the proper manipulation of 
the instrument afford valuable information. 

The mobility of the membrana and ossicles should be de- 
termined as the next step of the examination. This may be 



* Rev. mens, de laryngol., vol. x, p. 681. 
f Trans. Am. Otol. Society, 1872. 



THE PNEUMATIC SPECULUM. IO i 

done by making use of Siegle's speculum (Fig. 42). It con- 
sists of a hard -rubber speculum, the wider extremity of 
which is screwed tightly into one end of a short cylinder of 
the same material as the speculum, while the extremity in- 
troduced into the canal is covered with a small bit of rubber 
tubing to effect an air-tight closure of the meatus. The op- 



Fig. 42. — Siegle's pneumatic speculum. 

posite end of the cylinder is closed by a cap which makes an 
angle of forty-five degrees with the axis of the instrument. 
In the centre of this cap is an opening covered with glass. 
Upon one side of this cylindrical chamber is an opening into 
which a short tube is screwed. The free extremity of the tube 
is connected with a small air pump, bellows, or atomizer bulb 
by a short piece of flexible-rubber tubing. 

After the speculum has been carefully inserted into the 
external auditory meatus, the air in the canal can be exhausted 
by means of the small air pump or rubber bulb with which 
the instrument is provided, or the flexible tube may be held 
between the lips and the air withdrawn in this manner. The 
density of the air in the meatus can be increased if desired by 
reversing the direction of the current. The glass in the outer 
extremity of the instrument permits the examiner to watch the 
different motions of the membrana tympani and ossicles, caused 
by the alternate condensation and rarefaction of the air in the 
canal. Were the glass at right angles to the axis of the 
speculum, the reflection of the illuminating rays would inter- 
fere with the view of the deeper parts, but this is avoided if it 
is placed at an acute angle. Under normal conditions the drum 
membrane moves outward each time the air in the canal is 
rarefied, and passes in the opposite direction when condensa- 
tion is effected, the motion being most evident in the postero- 



102 PHYSICAL EXAMINATION. 

superior quadrant. The malleus at the same time rotates 
about the axis band, the short process remaining almost im- 
movable, while the long process participates in the outward 
excursion of the membrane. Areas over which the membrane 
is adherent to the inner tympanic wall are easily recognized, 
since they are not affected by changes in the air pressure. It 
is also important to note closely the motion of the malleus, for 
if bound down at its tip any outward excursion is impossible. 
Under these circumstances it either remains fixed, the mem- 
brane bulging beyond it in front and behind, when the air is 
exhausted, or it may move slightly outward at its upper part 
when there is relaxation of the structures in this locality. 
Sometimes intratympanic adhesions fix the malleus in such a 
manner that, instead of rotating about the axis band, it rotates 
upon its long axis. This is frequently observed in cases where 
the entire ossicular chain and the membrana are drawn inward 
as a whole by adhesions, the membrane, therefore, giving no 
marked evidence of malposition except that it appears farther 
from the entrance of the meatus than usual. When the ex- 
cursions of the malleus are changed in character, so that rota- 
tion takes place about the long axis of the ossicle, we are 
warranted in assuming the presence of extensive intratym- 
panic adhesions, together with some relaxation at the malleo- 
incudal articulation. 

The use of a magnifying lens in connection with the pneu- 
matic speculum is seldom of advantage, the unaided eye dis- 
tinguishing variations from the normal quite as readily as 
when a lens is used. 

Our physical examination has thus far been confined to 
those parts of the conducting mechanism which can be inves- 
tigated by sight and by touch. We now have to call to our 
aid the sense of hearing for the examination of parts not ac- 
cessible to ocular inspection. These parts are the Eustachian 
tube and the tympanic cavity. 

Inflation of the Tympanum. — Since the tympanum com- 
municates with the pharyngeal vault through the Eustachian 
tube, a sudden condensation of air in the vault of the pharynx 
will cause a corresponding increase in air pressure in the mid- 
dle ear, provided the Eustachian tube is open. The tym- 
panum is separated from the external meatus only by the thin 
membrana tympani, and the examiner, by inserting a flexible 
tube into the meatus of the patient while the other extremity 



INFLATION OF THE TYMPANUM. I03 

is inserted into his own auditory canal, is able to recognize 
the moment when the air enters the tympanum, by its impact 
upon this delicate partition. The sound produced under nor- 
mal conditions when the tympanum is suddenly inflated we 
may denominate, for convenience, the sound of impact. It 
is of sharp, metallic character, and is due to the stretching 
of the membrana tympani by the sudden condensation of 
the air within the middle ear. This sound seems to originate 
in the ear of the observer on account of the extreme thinness 
of the interposed partition, and the direct conveyance of the 
sound waves to his ear. Under normal conditions but a 
single sharp metallic click or snap is heard. This may be 
followed later by a similar sound of lower pitch and of less 
intensity, due to the return of the membrana to a condition 
of equilibrium in virtue of its elasticity. A familiarity with 
these signs in health enables the observer to interpret cor- 
rectly the significance of any modification in their character 




Fig. 43. — Auscultation tube. 

due to pathological conditions. It is sometimes stated that 
auscultation is a procedure of little diagnostic value, but I can 
only say that the otologist who would take this ground, might 
be compared with a physician who would consider himself 
able to judge of intrathoracic conditions without availing 
himself of auscultation of the chest. Auscultation certainly 
affords us a valuable means of recognizing certain conditions 
within the tympanum and Eustachian tube, if practiced suffi- 
ciently long to enable one to interpret the significance of the 
various sounds heard. 

Methods of Inflation. — The earliest method of inflation of 
the middle ear is that which bears the name of its discoverer, 
Valsalva. It is executed by the patient compressing the alas 
nasi between the thumb and finger of one hand, thus closing 
the nostrils ; at the same time the mouth is closed and the at- 



io4 



PHYSICAL EXAMINATION. 



tempt is made to force air through the nostrils — in other words, 
to blow the nose. The result is that the air is forced into the 
tympanum, since all other avenues of exit are closed. The 
procedure is frequently valuable as a diagnostic measure, as 
the surgeon can observe the effect of the increased intratym- 
panic pressure upon the drum membrane, by an inspection of 
the part while the patient performs the inflation. Depending 
as it does upon the patient himself for its efficiency, this pro- 
cess possesses but little therapeutic value. 

The most universally employed method of inflating the 
middle ear is that first brought into prominence by Politzer,* 

and bearing his name. To 
force air through the Eusta- 
chian tube by this procedure, 
the surgeon makes use of a 
balloon-shaped rubber bulb, to 
which a tube of the same ma- 
terial is attached ; the sudden 
compression of the bulb by the 
hand, expels the air through 
the free end of the tube with 
considerable force. This ex- 
tremity of the tube is provid- 
ed with a hard-rubber tip, so 
shaped that it may be inserted 
into the nostril of the patient, 
or in some instances it is coni- 
cal in form so as to occlude 
the nostril. In inflating with 
this instrument, the nose piece is held in position by the fin- 
gers of the surgeon's left hand, the other nostril being oc- 
cluded at the same time by compressing the alae of both sides ; 
the patient is then directed to take a small quantity of water 
into the mouth, and to swallow it at a given signal. Coinci- 
dent with the act of deglutition the physician compresses the 
bulb, which he holds in the right hand, by quickly and firmly 
closing the fingers upon it, thus driving the air within it into 
the pharyngeal vault, and from thence into the tympanic cavi- 
ties through the Eustachian tubes. The action of swallowing 
shuts off the pharyngeal vault completely from the oro-phar- 




Fig. 44. — Politzer's air-bag. 



* Wien. med. Woch., 1863, No. 6. 



POLITZERIZATION. 



105 



vnx, by the elevation of the soft palate, the muscular action 
effecting this, at the same time serving to render the tube 
more permeable, in the manner already described in consider- 
ing the function of the tubal muscles. Various modifications 
of 1 this procedure have been devised, the success depending 
largely upon the intelligent co-operation of the patient. The 
act of swallowing must be coincident with the compres- 
sion of the inflating bulb ; otherwise, the naso-pharyngeal 
space will not be shut off, and an imperfect operation will be 
the result. When this occurs, the operator not only fails to 
carry out the measure intended, but occasions great discom- 
fort to the patient, and occasionally to himself, for the sud- 
den entrance of the air into the oro-pharynx forces the water 
which the patient is attempting to swallow, either into the 
larynx, bringing on a severe seizure of coughing, or out of his 
mouth, deluging himself and operator as well. 

The modifications of the Politzer method have been de- 
signed to obviate such accidents. One of the best is to direct 
the patient to close his lips and then puff out the cheeks, as 
though trying to whistle w T ith the mouth closed. Another 
fairly successful method is to repeat rapidly the letter K, or 
any syllable containing the K sound. Either of these proced- 
ures, causing an elevation of the soft palate, effects a fairly 
perfect closure of the pharyngeal vault. These modifications 
are of particular convenience in children, and render the oper- 
ation much less uncomfortable. In infants the act of crying 
produces sufficient closure of the naso-pharygneal space to 
allow of a successful inflation of the middle ear, if the air bag 
is forcibly compressed while the child is crying. 

There can be no question of the value of Politzer's method 
both as a diagnostic and therapeutic procedure, but its use 
should, I think, be restricted to certain cases, and it should 
not be adopted to the exclusion of catheterization of the tube. 

A few words will not be out of place here regarding the 
selection of a proper inflating bulb, or Politzer bag, and of a 
proper tip for the instrument. The error usually made is to 
choose an unnecessarily large bag. A large instrument is 
cumbersome and at the same time less efficient, since it can 
not be so grasped that the hand is able to compress it quickly. 
The lumen of the delivery tube is frequently so small in pro- 
portion to the size of the bag, that when a sudden effort at 
compression is made, very little air is forced out, the ten- 



I0 6 PHYSICAL EXAMINATION. 

sion in the bulb almost immediately reaching such a degree 
that further compression is impossible. The use of a small 
bulb, of not more than four ounces' capacity, is attended with 
more satisfactory results ; the instrument can be easily held 
in the palm of the hand, so that the fingers encircle it, and 
can be almost completely emptied when the hand is quickly 
closed upon it. The actual air pressure obtainable with a 
bulb of moderate size is greater than with one of large di- 
mensions. It is immaterial whether the air bag is provided 
with a valve which allows the entrance of air, but closes when 
the bulb is compressed, or whether it has but a single open- 
ing, in which case the free end must be removed from the 
nostril after each act of inflation. When this last form of bag- 
is employed it must be removed from the nostril before the 
pressure upon the bag is relaxed ; otherwise, the mucus from 
the nasal cavity will be sucked up into the tube. To prevent 
this accident it is also important that the tip be wiped imme- 
diately after removal, either with cotton or with a towel, and 
before allowing the bag to refill. It is more convenient cer- 
tainly to use a bag provided with a valve, although even here, 
if the nose piece is allowed to remain in position, a certain 
amount of mucus may be aspirated from the nasal cavity. 
The objection to the valve lies in the fact that it is liable to 
get out of order. This difficulty may be obviated by cutting 
a hole in the side of the ordinary bag, and covering the open- 
ing with the hand during the act of compression ; as the fin- 
gers are relaxed it is uncovered, thus allowing the balloon to 
fill readily. This is certainly more simple than any automatic 
valve, and demands only a little attention on the part of the 
operator to see that perfect closure of the opening is effected 
at each act of inflation. Personally, I often use a very small 
bulb of a capacity of about two ounces, such as is supplied 
with the ordinary hand-ball nasal atomizer. The valves in 
these instruments are fairly w T ell made, and do not get out of 
order readily. The one which I prefer has two valves, one 
allowing the air to enter at the distal end of the bulb, while 
at the same time a valve at the opposite extremity closes the 
channel between the bulb and the nasal cavity of the patient, 
preventing the entrance of mucus. Thio small bulb is also 
particularly adapted for use with the catheter, it being only 
necessary to change the tip. 

Regarding the particular form of tip suitable for insertion 



CATHETERIZATION. i Q y 

into the nostril, individual preference will probably be the 
best guide. Many advocate the use of a small, curved hard- 
rubber tip. This tube is inserted into the inferior meatus, 
where it is held between the ringers and thumb of the left hand, 
which at the same time compress the alas nasi so tightly as to 
allow no air to escape. I have never been able to use this in- 
strument to my own satisfaction, although there is no question 
that it is perfectly efficient in other hands. The objection to 
its use is that the introduction of the tube into the nostril may 
be painful, if the septum is considerably deflected, and even 
when the greatest care is used, slight haemorrhage may follow 
the procedure. If this form of tip is chosen, care should be 
taken that its calibre is ample, permitting a large volume of 
air to pass through it. As the instrument is usually sold in 
the shops, the bore is very small in comparison with the ex- 
ternal diameter of the tube. It is also wise to cover the end 
of the tube to be introduced into the inferior meatus with 
a piece of thin rubber tubing, as an abrasion of the nasalmu- 
cous membrane is less liable to be caused if this is done. 

For my own use I prefer a conical tip, which occludes 
the anterior nasal opening perfectly by the coaptation of its 
surface with the soft walls of the opening into which it is in- 
serted. This conical tip may be constructed either of glass, 
hard rubber, or aluminium, and care should be taken that the 
opening through it is of sufficient size to allow a free passage 
of the air when sudden condensation is effected. In children 
this conical tip is unquestionably more effectual and more 
easily manipulated than the one previously mentioned. 

Catheterization of the Eustachian Tube. — By this manipu- 
lation the surgeon directs a current of air into the tympanum 
of one side or the other, by means of a canula, which is passed 
through the nasal passages into the vault of the pharynx and 
inserted directly into the Eustachian orifice. 

Before giving a detailed description of the method of intro- 
ducing the instrument, a few words may be said concerning 
the catheter itself (Fig. 

45). It consists of a tube ^ Bass^^ 

of either hard rubber, v ® ® © © ^ 

pure or coin silver, or FlG . 45 ._ T he Eustachian catheter. 

of German silver, about 

eight inches long, bent in the arc of a circle at one extremity, 

while at the other it is expanded into an elongated funnel, 



I0 8 PHYSICAL EXAMINATION. 

which constitutes about an inch of its length. The canulae 
vary in external diameter from No. 3 to No. 6 of the French 
scale. The expanded end of the catheter is provided with a 
guide ring, fastened to that wall of the tube corresponding to 
the concavity of the arc described by the pharyngeal extrem- 
ity, for the purpose of informing the observer of the position 
of the beak of the instrument when in the nasal cavity. De- 
cided preference should be given to the pure silver instru- 
ments, since the curve can be easily changed to meet the 
necessity of any individual case. German silver possesses too 
little flexibility to permit of the instruments being easily bent, 
while the hard-rubber instruments, although they can be molded 
into any form, after they have been heated, usually possess so 
small a lumen in comparison with the external diameter of the 
tube, as to render them unfit for use. Even in the pure silver 
instruments this objection occasionally exists, the walls being 
unnecessarily thick, and attention should be directed to this 
point in selecting the catheter. Care should also be taken that 
the margin of the lumen of the pharyngeal extremity is smooth, 
so as not to abrade the mucous membrane with which it comes 
in contact. Hartmann * advises that the tip shall be slightly 
bulb-shaped for this reason. This is not necessary if care is 
taken that the margins of the opening are slightly inverted, 
making the periphery perfectly smooth. As to the proper 
size of catheter, it is ordinarily stated that the largest instru- 
ment which can be introduced through the nasal passages 
should be employed, and in some instances an instrument of 
large calibre is of service. It should be remembered that the 
w r idth of the isthmus of the tube is never greater than one 
tenth of an inch, and usually its diameter is less than this ; 
therefore there can be no advantage in using a catheter 
whose calibre is many times greater than this. If the tube is 
obstructed, a small instrument is even more efficient, since the 
column of air w T ill exert a greater pressure than when a large 
instrument is used. Any advantage gained by an instrument 
of large size is, I think, more than counterbalanced by the in- 
creased delicacy of manipulation which the smaller allows, 
enabling the operator to locate it more exactly. Regarding 
the proper curve of the instruments, this must of necessity 
vary in different cases, according to the width of the pharyn- 

* Krank. des Ohres, Berlin, 1889, p. 44. 



CATHETERIZATION. I09 

geal vault, the prominence of the tubal orifices, and the irregu- 
larities met with in the nasal chambers. 

Buck* advises that the curve of the catheter be long and 
gradual, and finds this form adapted to a greater number of 
cases than one in which the radius of the arc is shorter. This 
shape is especially valuable where the inferior meatus is ob- 
structed by a ridge located rather low down on the septum. 
Many times a sharper curve, such as advocated by Urbant- 
schitsch,f will be found to give a more perfect inflation. 
Herein lies the advantage of the pure-silver instrument, since 
it can be molded easily into any desired form, according to 
the demands of each case. It is of some importance that the 
catheter shall not be so long that when in position it projects 
more than an inch and a quarter beyond the nasal opening. 
It is more difficult to maintain the instrument in a fixed posi- 
tion if it projects farther than this, since any slight motion 
serves to displace it from the tubal orifice. When the project- 
ing portion is short very little leverage can be obtained, and 
there is less possibility of inflicting injury upon the delicate 
structures encountered, in the event of rough manipulation. 

The particular device to be used for effecting inflation 
has been discussed thoroughly, each form having its advo- 
cates. The ordinary Politzer bag is most commonly em- 
ployed, the delivery tube terminating in a conical tip which 
fits into the outer end of the catheter exactly ; or, in some 
instances, the tip is larger than the mouth of the catheter, the 
bag being so held at the moment of compression that the tube 
is applied as closely as possible to the mouth of the cathe- 
ter, but not fitting into it tightly, thus preventing undue pres- 
sure at the moment of condensation of the air. When a valve- 
less air bag is used in this manner it must be removed after 
each act of compression to allow it to refill, and the repeated 
adjustment to the lumen of the catheter can not but disturb 
the position of the instrument, and be a source of discomfort to 
the patient. It is much simpler to make use of the ordinary 
atomizer bulb, provided with a valve at either extremity and 
connected with the catheter by a piece of rubber tubing 
about twelve inches long. The delivery tube is joined to the 
catheter through the interposition of a conical tube ground 
to fit the catheter exactly ; this allows a free manipulation of 

* Op. cit. \ Lehrb. der Ohren., Wien, 1890, p. 8„ 



IIO PHYSICAL EXAMINATION. 

the bulb, without any motion being imparted to the catheter 
when it is once in position. When this apparatus is used the 
hard-rubber tube is fitted into the catheter before the instru- 
ment is introduced into the nose, the small size of bulb ren- 
dering it possible to grasp this in the palm of the hand, while 
the fingers of the same hand hold the catheter and manipulate 
it during its passage through the nasal cavity (Figs. 46 and 
47). This allows of great freedom of manipulation, on account 
of the length of the tube which joins the catheter to the bulb. 
After the catheter is once in place the fingers of the left hand 
fix it, while with the right hand the surgeon compresses the 
bulb as many times as may be necessary. No motion is com- 
municated to the instrument as the bulb is emptied, and no 
discomfort attends the operation. Certainly from a humane 
point of view this method is to be preferred ; and it may also 
be said that since the mechanical irritation is reduced to a 
minimum the therapeutic value is also greater. 

Lucae * advises the interposition of an elastic bulb be- 
tween the inflating bag and the catheter to serve as a re- 
ceiver, which is filled by the compression of the inflating bag. 
The elasticity of this second bulb permits of the introduction 
of a continuous current of air into the tympanum. It has 
never in my experience seemed necessary that the current of 
air should be continuous, and for diagnostic purposes cer- 
tainly, it would be of less value than an intermittent current. 

Many Continental otologists advocate the use of a higher 
air pressure than can be obtained by any of the above instru- 
ments, and employ some form of air pump to secure the 
proper amount of tension. In such an instrument the air is 
forced by the pump into a large receiver, provided with a 
gauge for registering the degree of condensation. The 
Eustachian catheter is connected with this receiver by means 
of a flexible tube, and the air is allowed to escape through 
the instrument by means of a properly adjusted cut-off. 

When the Eustachian tube is so much obstructed that 
catheter inflation is impossible with the ordinary air bag, some 
method should be employed to determine the exact nature of 
the obstruction, rather than to attempt to perform inflation 
with very high air pressure. The same remark will apply to 
the use of any form of foot bellows for a similar purpose. Re- 

* Archiv fur Ohrenheilk., vol. ii, p. 308. 



CATHETERIZATION. 



Ill 



garding all of these devices, it should be borne in mind that, 
as a diagnostic measure, considerable information is gained 
by estimating the amount of force necessary to empty the 
bag by compressing it in the palm, in order to secure a free 
entrance of air into the tympanum, as evidenced by auscul- 
tatory signs. The hand and ear of the operator then act 
together, allowing him to interpret the relation between the 
intensity of any particular sound heard, and the force neces- 
sary to secure the degree of pressure requisite to force the 
air into the tympanum and produce the sound. 

An appropriate catheter and inflating apparatus having 
been selected, the next step is the technique of inserting the 
instrument. The plan which seems most simple will be first 
described, after which other methods will be detailed. 

The inflating bulb is held in the palm of the right hand, 
while the catheter, having been properly connected with it, is 
grasped lightly between the thumb and index and middle fin- 
gers of this hand, much as 
a pen is held. The shaft 
of the instrument points 



^^ 





FlG. 46. — Introduction of the Eus- 
tachian catheter (first step). 



Fig. 47. — Introduction of the Eus- 
tachian catheter (second step). 



directly upward, while the curved pharyngeal portion lies 
in the horizontal plane, the orifice of the catheter looking 
forward. The patient should be seated in a chair with a 
high back, and the head should be inclined forward slightly, 
while at the same time he should be directed to close the lips 
tightly and breathe slowly and quietly through the nostrils. 
The operator, either standing or sitting at the right of the pa- 



112 PHYSICAL EXAMINATION. 

tient, tilts the tip of the patient's nose upward with the ball 
of the left thumb, the index and middle fingers resting upon 
the nose just below the bridge. From this moment the left 
hand is not removed from the patient's nose until inflation has 
been accomplished and the catheter has been removed. The 
tip of the nose being elevated, the extremity of the catheter is 
introduced into the nostril (see Fig. 46) ; as soon as the instru- 
ment has passed the slight ridge at the nasal orifice the opera- 
tor carries the hand holding the instrument upward until the 
catheter assumes a horizontal position. In this position, with 
the tip kept constantly upon the floor of the nasal cavity, the 
catheter is passed directly backward through the inferior 
meatus until the posterior pharyngeal wall is encountered 
(Fig, 47) ; it is then drawn forward about three eighths or one 
fourth of an inch, and, remembering that the guide ring on 
the shaft indicates the direction in which the pharyngeal ex- 
tremity points, the instrument is rotated upon its long axis 
until the ring points almost directly outward toward the side 
to be inflated. The hand is then elevated a little and carried 
slightly toward the opposite ear, causing the pharyngeal ex- 
tremity of the instrument to descend, and at the same time to 
press lightly against the lateral pharyngeal wall. By drawing 
the catheter a little outward, the tip will be felt to impinge 

upon the posterior lip of the tube ; it 
is to be drawn over this, the tip being 
turned slightly downward, if neces- 
sary, to effect this without undue 
force. As soon as the operator knows 
by the sense of touch that the promi- 
nent posterior lip has been passed, the 
catheter is rotated upon its long axis 
until the guide ring points upward 
Fig. 48.— Introduction of the and outward toward the ear, while at 
Eustachian catheter (the in- the same time the outer extremity of 

strument fixed in the mouth . . , 

of the tube). the instrument is moved toward the 

opposite side, thus pushing the pharyn- 
geal extremity well into the mouth of the tube. When care- 
fully placed, the sense of fixation imparted to the hand is un- 
mistakable. At this juncture the left thumb is moved so as 
to pass beneath the catheter and support it. The instrument 
is thus held firmly against the margin of the nostril, by the 
thumb below and the first three fingers, resting upon the 




AUSCULTATORY SOUNDS. II3 

bridge of the nose, above (Fig. 48) ; at the same time the tip of 
the nose is pressed upward as before. The right hand is now- 
free to compress the bulb, forcing the air through the catheter 
into the middle ear, its entrance being recognized by sounds 
heard through the auscultation tube. 

As already stated, the value of auscultation for diagnostic 
purposes can not be overestimated, and the catheter is much 
superior to other methods of inflation when the operation is 
performed as a diagnostic measure only. The amount of 
manual pressure necessary to force the air into the tympanum 
is also of importance in determining the degree of obstruction 
present, and this may be roughly estimated by the operator 
with each act of compressing the bulb. The various sounds 
produced afford exact information as to the physical condi- 
tion of the mouth of the tube, of the tubal canal, and of the 
tympanum. These advantages are not offered by the Politzer 
method of inflation, since the efficiency of the procedure de- 
pends entirely upon the ability of the patient to close the 
naso-pharyngeal space completely at the proper moment. In 
catheterization the operator has the entire control of the pro- 
cedure, and from knowledge derived by the sense of touch as 
to the exact location of the catheter, and by an estimate of 
the force employed during the act of inflation, he is able to 
derive valuable information from the various auscultatory 
sounds elicited during the experiment. 

Auscultatory Sounds. — We may consider that the sounds 
heard through the auscultation tube are produced either at 
the pharyngeal orifice of the tube, or within the lumen of the 
canal, or within the tympanum. Frequently the ear analyzes 
the impression made upon it during such an examination, re- 
solving the combination of sounds heard, into the several sim- 
ple sounds produced at each of these locations. 

The determination of the point at which a given sound is 
generated consists in measuring its intensity or its proximity 
to the ear of the examiner. Since the tympanum of the pa- 
tient is separated from the lumen of the diagnosis tube simply 
by the drum membrane, any sound produced by the air 
entering the tympanum will appear to originate in the ear of 
the examiner. We also remember that, on entering the tym- 
panum, the current passes from a narrow canal into a cavity 
of comparatively large size, and we should expect that its 
character would be modified by this change in the phvsical 
9 



ii 4 PHYSICAL EXAMINATION. 

conditions, so that the pitch would be lowered and the qual- 
ity softened. 

On the other hand, sounds originating in the Eustachian 
canal would be of higher pitch, but would impress the listener 
as though they came from a greater distance from his ear 
than the tympanic sounds. Auscultation sounds originating 
in the naso-pharynx or at the pharyngeal orifice of the tube 
will seem still more distant, being heard quite as well with 
the open ear as through the auscultation tube. 

The Normal Tympanic Bruit. — With the parts in a normal 
condition the surgeon hears with each compression of the 
bulb of the inflating apparatus a soft, dry, blowing sound, 
together with a slight but distinct percussion sound due to 
the impact of the current of air upon the drum membrane. 
This last is compared by Deleau * to drops of rain as they 
fall upon foliage in the forest during a shower. The " blow- 
ing sound " is produced by the passage of the aerial current 
through the catheter and Eustachian tube into the cavity 
of the tympanum; the " impact sound," by the obstruction 
offered by the membrana tympani to the farther progress of 
the air. With the membrane in a proper position and under 
normal tension, this last sound is but slightly marked, and 
may be so indistinct as to be entirely overlooked. It is 
possible, however, with care, to make out the tympanic, tu- 
bal, and pharyngeal components of the auscultation sound in 
almost every instance. We have next to examine the vari- 
ations which the normal auscultation sound undergoes when 
the various parts are not in a condition of health. We will 
consider these according to the special region in which they 
arise. 

i. Tympanic Sounds. — (a) An exaggeration of the " impact 
sound " indicates a considerable displacement outward of the 
membrane under the influence of the increased tympanic pres- 
sure. Hence the membrane must have been retracted, oc- 
cupying an abnormal position — a fact already determined by 
previous speculum examination ; or, if occupying a normal 
position, it must have been so relaxed as to admit of consid- 
erable outward displacement by the aerial condensation. If 
this last condition exists a secondary sound will be heard, as 
the hand holding the bulb relaxes, thus allowing the pressure 

* Acad, de Sci., Dec. 7, 1829. 



TYMPANIC SOUNDS. U 5 

in the middle ear to diminish, by the escape of the air from 
the tympanum through the tube into the pharyngeal vault. 
The amount of air forced backward in this way, and conse- 
quently the intensity of this secondary sound, will depend 
upon the resiliency of the membrana tympani and the exact- 
ness with which the catheter fits the pharyngeal orifice. This 
secondary sound is sharp and similar to trie original " impact 
sound," but less intense. 

Sounds having their origin within the tympanum are 
heard so distinctly that those not accustomed to the use of 
the auscultation tube will frequently describe them as origi- 
nating within their own ear. 

(b) If now the tympanic cavity is filled with fluid the nor- 
mal " blowing " and " impact " sounds undergo a change, so 
that a rough bruit is observed in place of the " blowing 
sound," accompanied and followed by a series of sharp crack- 
ling rales following each other at irregular intervals, and 
persisting for a short period as the inflating bulb is allowed 
to refill. This rattling appears to be in the ear of the exam- 
iner, and conveys the impression of a current of air being 
driven through a collection of fluid. The quality of these 
rales gives some hint as to the nature of the fluid. Crepita- 
tation of a fine, high-pitched character is heard when the fluid 
is watery, but the rales are coarse, low-pitched, and bubbling 
when the liquid is thick and viscid and adheres to the walls 
of the cavity. These distinctions are of but little importance, 
as the exact nature of the fluid is of no moment. It must also 
be remembered that even if fluid is present, it may lie out 
of the course of the current of air which enters the cav- 
ity, and the auscultation sound may afford no evidence of its 
presence. 

(c) When the cavity of the tympanum is completely filled 
with fluid no crepitation is heard, as the air fails to enter the 
middle ear at all, and the normal " blowing sound " is also 
wanting. The " impact sound," however, is heard as the 
current of air enters the tube and impinges upon the fluid 
contained in the tympanum. The percussion sound, how- 
ever, loses its sharp character, appearing indistinct, distant, 
and low-pitched. 

(d) Any solution of continuity in the drum membrane is 
easily discovered upon forcing air through the Eustachian 
tube, provided the opening through the membrana is not 



u6 PHYSICAL EXAMINATION. 

completely shut off from the Eustachian canal by adhesions. 
The character varies with the size of the opening, being 
high-pitched and whistling when this is small, and of a blow- 
ing quality when the area destroyed is greater. With exten- 
sive destruction of the membrana the air is felt to enter the 
canal of the examiner and to impinge upon the walls of the 
meatus. The pitch of the note heard when the perforation 
is of moderate size will depend somewhat upon the thickness 
of its edges. Where the drum membrane is greatly swollen 
the edges do not vibrate freely and the sound is rather low- 
pitched. Where the thickening is not excessive, and espe- 
cially if the membrane is fairly tense, a high-pitched note, 
known as the " perforation whistle," is heard. 

(e) Certain sounds comparable to those heard when two 
moist surfaces are forcibly separated are frequently per- 
ceived upon inflation, and, from their apparent proximity to 
the ear of the examiner, evidently originate within the tym- 
panic cavity. They are caused by the separation of the 
membrana from the inner tympanic wall, by the act of infla- 
tion, and are met with in cases where slight hypersecretion 
has taken place, allowing the two opposing surfaces to adhere. 
Occasionally these signs indicate the rupture of newly formed 
adhesions. 

(/) When the middle ear is the seat of adhesive inflam- 
mation, which diminishes the size of the cavity by drawing 
the drum membrane inward, or when this structure itself is 
thickened and rigid from connective-tissue hyperplasia or 
from calcareous deposits, or where the tympanic orifice of 
the tube has been greatly narrowed, the tympanic factor of 
the bruit is practically lost, and the sound seems distant. 
This is observed most frequently in patients of advanced years. 

2. Tubal Sounds. — In passing through the Eustachian canal 
the column of air is thrown into vibration, producing sounds 
which vary in character according to the patency of the pas- 
sage, the condition of the walls, and the presence or absence 
of moisture. When the air is not heard to enter the tym- 
panum, but the listener is conscious of a distant harsh blowing 
sound with each act of inflation, the catheter being correctly 
placed, but one interpretation can be made of the sign — it 
must indicate stenosis of the channel. The location of the ob- 
struction is determined by observing the relative distance at 
which the sound appears to be from the ear of the examiner. 



TUBAL SOUNDS. Yl y 

It approximates more nearly to the pure pharyngeal sound 
according- as the barrier is located nearer this orifice. When 
the bruit is fairly constant in quality and intensity, the nar- 
rowing may be looked upon as depending upon some organic 
change in the tubal walls. 

On the other hand, if its character changes with each act 
of compression of the air bag, then it is probable that the 
lumen of the tube is closed either by a plug of secretion or by 
tumefaction of the lining membrane. In the first instance the 
listener hears a harsh, moist, rasping sound, the pitch of which 
varies each time the air is forced inward, while occasionally 
the current will be heard to rush into the middle ear. This 
is caused by the momentary displacement of a mass of tena- 
cious mucus which occludes the channel, permitting the air 
to enter. Prolonged inflation usually dislodges the obstruc- 
tion and allows the current to enter the tympanum with each 
compression of the bulb. 

When the tube is narrowed in calibre at any point by 
slight swelling or by a hyperplastic process, the blowing 
sound is of higher pitch, according to the degree to which 
the channel is narrowed, being of the squeaking or whistling 
character when the stenosis is nearly complete. When due to 
a hyperplastic process the sound varies but little as inflation 
continues, while if it depends simply upon swelling of the 
walls of the passage, the mucous membrane being at the same 
time moist, the bruit changes considerably in quality as the 
operation is continued, moist, crackling, or snapping sounds 
being heard from time to time, which modify the high-pitched, 
whistling note. The sensation of proximity to the observer is 
wanting, and this fact indicates the tubal origin. 

When the walls of the tube are in contact, as the result of 
oedema, the air frequently fails to enter the passage when an 
attempt is made to compress the bulb, the catheter, if properly 
located, seeming to be completely occluded. A slight move- 
ment of the instrument and repeated efforts at inflation pro- 
duces a distant clicking noise, followed by a high-pitched 
whistle, and the air is felt to rush into the middle ear sudden- 
ly. This phenomenon repeats itself during the operation, the 
air entering the tympanum only after the bulb has been com- 
pressed several times, and then but in small quantity. 

It is scarcely necessary to call attention to the signs ob- 
served where the tube is abnormally patent ; one need only 



Il8 PHYSICAL EXAMINATION. 

remember that the intensity of the tympanic sound must be 
greater if the tube is of wide calibre than if it is narrowed. 
The same is true of the intensity of the tubal sound itself. At 
the same time there will be no resistance to compression of 
the bulb. 

3. Pharyngeal Sounds. — These sounds are easily recognized 
by their variable character ; they are heard also quite as well 
through the air as through the diagnosis tube. Even when a 
perfect inflation is made under normal conditions a soft, indis- 
tinct blowing sound, depending upon the escape of a certain 
amount of air into the pharyngeal vault, is heard with the open 
ear. With partial or complete occlusion of the Eustachian 
canal, or when its pharyngeal orifice is filled with secretion, 
this sound becomes louder, and, if the trumpet-shaped orifice 
of the tube contains viscid mucus, is of a hoarse, rasping qual- 
ity as the air bubbles through it. While these sounds may be 
heard even when the instrument is correctly placed if the 
parts are swollen and inflamed, still they most frequently in- 
dicate that the catheter has been improperly manipulated, and 
that the tip lies in Rosenmuller's fossa, behind the tubal ori- 
fice. Occasionally the catheter is pressed so forcibly against 
the lateral wall of the pharynx as to completely occlude the 
lumen, and no air can be forced through the instrument upon 
attempting to perform inflation. A forcible effort at infla- 
tion may partially overcome the resistance, giving rise to a 
harsh, rasping sound as the current passes from the instrument 
and overcomes the elasticity of the mucous membrane which 
has occluded the opening. Sometimes, instead of lying ex- 
actly in the pharyngeal orifice, the instrument impinges upon 
the posterior lip of the tube. The pharyngeal bruit will pre- 
dominate if this is the case, and will be of a particularly dis- 
cordant, vibratory character, the cartilaginous plate forming 
the posterior wall of the tube being thrown into irregular vi- 
brations each time the bag is emptied. 

While the preceding description of these sounds may seem 
complicated, their recognition is simple after a little practice, 
and it is easy to recognize any undue prominence of the tubal, 
tympanic, or pharyngeal factors of the bruit. The informa- 
tion gained by close attention to this method of examination 
will amply repay one for the labor expended in perfecting him- 
self in it. 

But one method of introducing the catheter has been given 



METHODS OF CATHETERIZATION. 



19 



as yet, for the reason that it has seemed better to take this one 
as the standard, and to describe the variations in technique 
which may be resorted to when this first method, for any rea- 
son, is not successful. It is advisable for the beginner to ad- 
here closely to one method of catheterization rather than to re- 




FlG. 49. — Vertical section through nasal chambers and pharyngeal vault of adult. 
The lower portion of the septum, opposite the inferior turbinated body and the 
inferior meatus, has been removed, exposing the course followed by the cathe- 
ter. The Eustachian orifice is well marked. (Author's specimen.) 

sort to several as soon as difficulties arise, it being more easy 
to become expert in the manipulation by the constant use of 
one method. 

Loewenberg * modifies the technique in the following man- 
ner : When the pharyngeal extremity of the catheter is felt to 
impinge upon the posterior wall of the naso-pharynx the in- 



* Arch, fur Ohrenheilk., vol. ii, p. 12. 



120 



PHYSICAL EXAMINATION. 



Strumenl is rotated upon its long: axis so that the sruide rin^r 
shall be directed toward the opposite ear; the catheter is 
then drawn forward until its concavity is felt to engage the 
posterior margin of the nasal septum ; it is then rotated 
downward through an angle of one hundred and eighty 
degrees, until the guide points toward the ear to be inflated, 
while at the same time the catheter is carried toward this 
side. 

According to the writer quoted, when rotation has been 
completed, the beak of the instrument will be found to lie in 




Fig. 50. — A section made in the same manner as that shown in Fig. 49, showing the 
conformation of the parts in a child of five years. The pharyngeal vault is filled 
with adenoid vegetations, and the tubal orifice is less marked and lies farther 
forward than in the adult. (Author's specimen.) 

the mouth of the Eustachian channel. The prolonged manipu- 
lation is rather prone, in my experience, to cause a contraction 
of the muscles of the soft palate, and therefore constitutes a 
source of discomfort to the patient. The variations in the ex- 
act position of the tubal orifice and in the transverse diameter 
of the naso-pharynx, detract much from the special value of 
this method. The same technique had previously been advo- 
cated by Frank.* Boyer f prefers to rotate the instrument 



* Lehrb. der Ohren., 1845, p. 101. 

f Annal. des mal. de 1'oreille, 1877, vol. iii, p. 69. 



METHODS OF CATHETERIZATION. 



121 




upon its long axis, as soon as the tip passes the choanse, as 
recognized by the diminished sensation of resistance to the 
entrance of the instrument, until its extremity points to the 
affected side. Its 
exact insertion into / 

the tubal orifice is 
effected by pressing 
the beak outward 
toward the later- 
al pharyngeal wall. 
This method is oc- 
casionally of service 
when the parts are 
irritable, and the op- 
erator knows, from 
previous experience, 
the exact location of 
the tubal opening. 

Triquet* follows 
almost thesameplan, 
but rotates the cath- 
eter before it leaves the inferior meatus, so that it may be arrest- 
ed by the tubal prominence as it is pushed farther backward. 

Wolff f and Gruber £ advise that after the instrument, 
with the pharyngeal extremity directed downward, has been 
passed through the inferior meatus until the pharyngeal wall 
is reached, it shall be drawn forward until it is arrested by 
the soft palate ; it is then advanced slightly toward the pos- 
terior pharyngeal wall, after which the angular portion is 
rotated toward the ear to be inflated, causing the extremity 
to enter the tubal mouth. 

Kramer # suggests that use be made of the reflex contrac- 
tion of the soft palate, which is excited by the presence of the 
catheter, to cause the instrument to assume its correct posi- 
tion in the tubal mouth. Having carried the catheter backward 
to the posterior wall of the naso-pharynx, it is drawn forward 
over the prominent posterior lip until it impinges upon the 
soft palate. This manipulation is followed by a contraction 



Fig. 51. — A section through the nasal passages and 
naso-pharynx in an infant, showing the turbinated 
bodies and tubal orifice. The lips of the tube are 
poorly defined. A similar condition is frequently 
met with in advanced life. (Author's specimen.) 



* Traite pratique des mal. de l'oreille, 1857. 

f Lencke's Handb. der Ohrenheilk., vol. iii, p. 358. 
% Lehrb. der Ohrenheilk., Vienna, 1S88, p. 203. 

# Ohrenkrankheit., 1836, p. 248. 



I2 2 PHYSICAL EXAMINATION. 

of the palatal muscles, which forces the instrument upward. 
At this instant it is quickly rotated toward the affected side, 
the contraction of the palate crowding it into the tubal orifice. 

It will be seen that in all of these methods, with the ex- 
ception of Frank's, the technique of introduction is but 
slightly modified from that first described, and that the facil- 
ity with which the operation can be performed will depend 
greatly upon the ability of the operator to recognize the 
various structures which the pharyngeal extremity impinges 
upon, after the instrument has entered the naso pharynx. 

Obstacles to Catheterization. — Certain difficulties depend- 
ing upon anatomical characteristics peculiar to any given 
case may be encountered in attempting to perform catheter- 
ization. The most frequent obstacle is a considerable de- 
formity of the septum narium, causing a partial occlusion 
of the inferior meatus. Since the introduction of cocaine, 
catheterization has become much more simple, as the ex- 
sanguination of the turbinated tissues increases the dimen- 
sions of the cavity materially, while at the same time, on 
account of its anaesthetic properties, prolonged manipula- 
tion is possible. Before attempting to introduce the Eus- 
tachian catheter, it is always wise to make a careful ante- 
rior rhinoscopic examination, to determine the presence and 
nature of any obstruction. If a considerable obstructive 
lesion exists, the catheter may be introduced under direct 
inspection, the parts being illuminated by reflected light, 
and the eye directing the various movements of the instru- 
ment until it has entered the naso-pharynx. A ridge upon 
the septum, which extends horizontally toward the outer 
wall of the cavity, is perhaps the most perplexing condition 
found. The curve of the catheter must be such that it may 
traverse the inferior meatus beneath the obstructing ridge ; 
herein lies the advantage of a pure silver catheter, since 
it is a simple matter to change the curve of the instrument 
to suit the particular condition encountered in any case. 
It is not always possible to introduce the instrument with 
the curved extremity pointing downward, when a prominent 
ridge or excrescence presents anteriorly, and it is often ad- 
visable in such cases to turn the tip of the catheter to one or 
the other side, effecting its introduction into the cavity in the 
oblique diameter rather than in the vertical. Again, when 
there is a prominent ridge at the very entrance of the vesti- 



OBSTACLES TO CATHETERIZATION. 



123 



bule, and the passage beyond is obstructed as well, it may be 
necessary to enter the nasal cavity with the catheter so held 
that the concavity is directed upward, the convexity apply- 
ing itself to the depression just within the vestibule. In such 
a case, as soon as the naso-pharyngeal space is entered, the 
instrument should be rotated until it has assumed the proper 
position. This rotation should be made toward the unaf- 
fected side to avoid touching the lateral pharyngeal wall. 

It sometimes happens that the conformation of the parts 
will not allow the instrument to enter the inferior meatus, 
although the middle meatus may be capacious. In such an 
event, if the catheter is so bent as to increase the length of 
the angular portion, it is a simple matter to pass it through 
the middle meatus, above the obstruction, until the pharyn- 
geal wall is encountered ; after it has passed into the naso- 
pharynx the extremity of the instrument held in the fingers 
is elevated — a manipulation which will allow the long, angular 
part to engage in the tubal mouth upon rotation, although 
the horizontal portion of the instrument lies at a higher level 
than the entrance of the tube. Naturally, the greatest deli- 
cacy must be exercised in conducting this procedure, as from 
the increased length of the angular portion it will be easy to 
wound the delicate tissues of the naso-pharynx in rotating 
the instrument upon its long axis at the moment when the 
extremity is carried into the mouth of the tube. 

When one nasal passage is blocked so that the introduction 
of a catheter is impossible, it may be carried through the pas- 
sage of the opposite side, as advised by Deleau.* The curved 
portion of the catheter must be considerably longer than 
usual, and if the vault of the pharynx is unusually wide the 
procedure is not satisfactory, as a rule. The technique con- 
sists of carrying the instrument through the nasal passage of 
the opposite side, the free extremity resting upon and gliding 
along the floor of the inferior meatus. When the posterior 
pharyngeal wall is encountered the instrument is rotated so 
that the pharyngeal extremity points toward the ear to be in- 
flated. The catheter is made to enter the fossa of Rosenmiiller 
by carrying the extremity of the instrument held between the 
fingers away from the septum, until further motion is pre- 
vented by the lateral pharyngeal wall. The instrument is now 



Rev. med., 1827. 



124 



PHYSICAL K X A .\ 1 1 N AT ION. 



drawn outward for about one fourth of an inch, or until the 
prominent posterior lip of the tube is felt ; it is made to glide 

over this by drawing- it outward, 
while at the same time the outer 
extremity of the instrument is ele- 
vated so as to allow the angular 
portion to pass over the posterior 
lip of the tube close to its lower 
margin ; the outer extremity of the 
instrument is then carried away 
from the side to be inflated — a ma- 
nipulation which forces the pharyn- 
geal end into the mouth of the Eus- 
tachian tube. This method of ca- 
theterization is unsatisfactory to 
the surgeon and painful to the pa- 
tient, the length of the angular por- 
tion of the catheter making delicate 
manipulation an impossibility, while 
at the same time it projects so far 
downward that when the instru- 
ment is rotated, considerable irri- 
tation of the pharyngeal mucous 
membrane is produced. Noyes has 
devised a catheter (Fig. 52), the 
pharyngeal extremity of which is 
bent at first downward and then 
upward and outward, which en- 
ables catheterization to be per- 
formed through the opposite nostril 
somewhat more easily than when 
the ordinary Eustachian catheter is 
employed. If the operator uses the 
silver catheters, which, on account 
of their malleability, can be made 
to assume any desired curve, it is 
comparatively simple to convert an 
ordinary Eustachian catheter into 
one possessing a double curve by 
bending it between the fingers. By 
a careful inspection of the nasal passage through which the 
instrument is to be introduced, the operator will be able in 




OBSTACLES TO CATHETERIZATION. 



125 



many instances so to mold the instrument as to render its 
introduction comparatively simple. By giving it the double 
curve already described we overcome the necessity of the 
increased length of the angular portion, which is always a 
source of discomfort to the patient. 

One other method of catheterization remains to be de- 
scribed — viz., the introduction of the instrument through the 
mouth. This was first advised by Kessel * in cases in which 
the nasal passages were occluded. Pomeroy f in this coun- 
try has been an ardent advocate of the procedure, and fre- 
quently employs it in preference to the usual method. He 
has devised a special instrument which is shown in Fig. 53. 




Fig. 53. — Pomeroy's faucial catheter. 



As I have had no personal experience with this method, I can 
give no opinion as to its utility. It is simply mentioned here 
as an available procedure, which may be employed at the dis- 
cretion of the surgeon. 

Deformities of the nasal passages, however, are not the 
only obstacles to catheterization. The exact location, form, 
and prominence of the pharyngeal extremity of the Eustachian 
tube varies not only in different cases, but also in the same 
individual at different times, according to the degree of con- 
gestion of the surrounding parts. The position and shape of 
the pharyngeal orifices may also be asymmetrical in the same 
individual. It frequently happens that the tubal lips are so 
poorly developed that their recognition by the sense of touch 
is almost impossible ; on the other hand, they may be so ab- 
normallv developed that difficulty is experienced either in 



* Archiv fur Ohrenheilkunde, vol. xi, p. 218. 
f Diseases of the Ear, New York, 1883, p. 28. 



126 PHYSICAL EXAMINATION. 

drawing the instrument forward over the posterior lip or, in 
some cases, even in passing it backward sufficiently to permit 
rotation. The pharyngeal vault is occasionally so wide that 
upon rotation the catheter reaches the lateral wall with diffi- 
culty. In such an event the straight portion of the cathe- 
ter must be crowded so far toward the nasal septum as to 
cause considerable discomfort by pressure upon the intra- 
nasal structures, or the angular portion must be so long as 
to render the passage of the instrument through the nasal 
chamber difficult, and to render rotation almost impossible. 

Again, the mouth of the tube may be located high up in 
the vault of the pharynx, and its shape may be such that the 
catheter must be rotated through an angle of at least 1 35°, 
or even more, before its tip rests in the mouth of the tube so 
as to permit of a fully successful inflation. 

It is only necessary to bear in mind these various obstacles 
in order successfully to overcome them. Delicate manipula- 
tion will enable the operator to recognize the posterior lip of 
the tube after a little practice, even if it projects only slightly 
above the smooth lateral wall of the pharynx. Where the 
pharynx is abnormally wide, the curved portion of the instru- 
ment must be increased in length, and if rotation can not be 
accomplished in the ordinary way, the outer extremity of the 
catheter should be elevated as much as possible to effect a 
corresponding depression of the tip of the instrument, to 
enable it to pass below the tube, after which rotation can be 
performed easily. The timidity of the patient when catheter- 
ization is performed for the first time is another difficulty to 
be mentioned. This is especially the case if the mucous mem- 
brane of the nasopharynx is irritable, in which event the mus- 
cles frequently contract the moment the instrument enters 
the cavity, and hold it so firmly in their grasp as to prevent 
its rotation into the mouth of the tube. This spasm of the 
palatal muscles causes the instrument to be so firmly grasped 
that its mere presence in the pharyngeal vault is painful. 
The slightest motion augments this pain and increases the 
muscular rigidity, so that it is quite as impossible for the oper- 
ator to withdraw the catheter, as to proceed with the opera- 
tion. Occasionally no inconvenience is experienced until ro- 
tation is attempted, when contact with the lateral wall of the 
pharynx excites the act of deglutition, and the sudden mus- 
cular contraction displaces the catheter and crowds it against 



OBSTACLES TO CATHETERIZATION. 127 

the lateral wall of the pharyngeal space with considerable 
force. If the patient is directed, at the outset, to keep the 
mouth closed and respire regularly and quietly through the 
nostrils, there is much less danger of such reflex muscular 
contraction. If as the instrument enters the pharynx the pa- 
tient shows an inclination to cough or to swallow, it is well to 
divert his attention by requesting him to close the lips and to 
breathe quickly and deeply through the nose. Even an at- 
tempt to do this will cause a momentary relaxation of the 
palatal muscles, and during the interval the introduction of 
the instrument can usually be effected. If reflex contraction 
of the muscles takes place in spite of all precautions, the in- 
strument should be held perfectly still during the period of 
muscular spasm, as any attempt to withdraw or advance it 
adds seriously to the discomfort. Relaxation is sure to take 
place in a few seconds, and then the instrument can be carried 
to the proper position or removed, as seems desirable. Re- 
flex cough occurring during the act of catheterization should 
be managed in the same manner. It is to be remembered that 
when the instrument is once in position, coughing, swallow- 
ing, or any other muscular movement does not interfere with 
it in the slightest, and when correctly placed its presence 
causes no discomfort. 

It occasionally happens that, by mistake, the catheter is 
passed through the middle meatus instead of through the in- 
ferior channel. This need never occur accidentally if the 
head of the patient is maintained in a slightly flexed position. 
The almost irresistible impulse on the part of the patient to ex- 
tend the neck causes the instrument to enter the middle me- 
atus, even when it is passed horizontally inward. With the 
head bent slightly forward this can not occur. It must be 
borne in mind, in conclusion, after discussing the principal 
difficulties met with, and suggesting measures to avoid and 
overcome them, that the utmost gentleness must be exercised 
throughout the entire performance of the operation. The 
catheter should be allowed to find its way into the pharyngeal 
vault, and should be allowed to rotate one way or the other, 
as may seem necessary to avoid obstacles. It is only neces- 
sary for the operator to prevent its passage into the middle 
meatus. When the nasal channel is extremely irregular com- 
plete rotation about the long axis of the catheter frequently 
occurs during its course from the anterior to the posterior 



128 PHYSICAL EXAMINATION. 

nasal opening. The slightest pressure is sufficient to advance 
it when properly directed, and no force should be used. Any 
haemorrhage following catheterization is a reproach to the 
operator in every instance. It is true that an occasional abra- 
sion of the nasal mucous membrane occurs at the hands of the 
most careful manipulator, but one should always feel that 
there is no excuse for the accident. It is a procedure in 
which gentleness and care should be combined with skill, and 
he who can not exercise these is incompetent to carry out the 
operation. 

As to the use of cocaine for the production of local anaes- 
thesia, it may be said that since the drug has come into com- 
mon use, it is frequently employed for this purpose in cathe- 
terization. It certainly diminishes the discomfort attending 
the passage of the instrument through the nose, if the channel 
is irregular or narrow, and at the same time by shrinking the 
turbinated bodies increases the width of the nasal passage. 
It may be stated, however, that under normal conditions the 
inferior meatus is not sensitive to the presence of the instru- 
ment, and observations upon quite a large number of cases 
in reference to this point have convinced me that quite as 
much discomfort follows catheterization when local anaes- 
thesia is employed, as when no cocaine is used. In many, the 
disagreeable sensation as of a foreign body in the pharynx, 
due to the drug, constitutes a much greater source of dis- 
comfort than that produced by the introduction of the instru- 
ment without local anaesthesia. No objections can be raised 
to the use of cocaine, however, and it is always wise to em- 
ploy it in cases where the nasal passages are so tortuous as 
to necessitate rather prolonged manipulation. Moreover, the 
knowledge on the part of the patient that the drug has been 
used, certainly produces a profound mental impression, and 
relieves any anxiety as to the discomfort to be endured. The 
drug is best applied in a ten-per-cent solution, a small quan- 
tity being first sprayed into the nostril by means of an ordi- 
nary hand-ball atomizer. A few moments suffice to secure 
contraction of the turbinated tissues, during which time it is 
well to have the head inclined a little forward to prevent the 
passage of the solution into the pharyngeal vault. Next, a 
cotton holder, mounted with a small pledget of cotton mois- 
tened with the same solution, is to be passed through the in- 
ferior meatus, along the course to be traversed by the cathe- 



DANGERS OF CATHETERIZATION. l2 g 

ter, the manipulation being conducted under illumination 
from the head mirror. The applicator should not be carried 
beyond the choanae if the unpleasant sensation of fullness in 
the pharynx which the drug causes is to be avoided. If 
there is reason to suspect that the naso-pharynx will be un- 
usually irritable — a condition with which we frequently meet 
in cases of acute naso-pharyngitis— it is well to anaesthetize 
the mouth of the tube as well as the nasal passages. This is 
done by means of the cotton-tipped probe, the extremity of 
which is bent to correspond to the curve of the catheter. 
Under inspection, this instrument is to be passed through the 
nasal passage exactly as the catheter would be introduced, 
care being taken that the patient's mouth is closed, and quiet 
nasal respiration continued. The same manipulation em- 
ployed in the introduction of the catheter enables the cotton- 
tipped probe to be inserted into the orifice of the Eustachian 
canal, care being taken that the pledget is not saturated with 
the solution, as otherwise a considerable quantity will be 
spread over the pharyngeal mucosa. When the orifice of 
the tube is reached, the applicator is allowed to remain in 
this position for a few seconds to ablate completely the sensi- 
tiveness of the mucous membrane ; catheterization is now 
easily performed. In addition to securing local anaesthesia 
by the introduction of the cotton pledget in the manner al- 
ready described, the operator accomplishes another purpose, 
since he cleanses the orifice of the tube and removes any in- 
spissated secretion which may be present, and which would 
be an obstruction to successful inflation. 

The Dangers of Catheterization. — From the fact that 
three deaths have followed the procedure it is looked upon 
by those unacquainted with the operation with a certain de- 
gree of perturbation. Inflation in these fatal cases was per- 
formed by means of compressed air, the degree of condensa- 
tion being extreme. This method, as already stated, is seldom 
used at present, and it is safe to say that no damage can be 
done with any form of hand apparatus devised for the purpose 
of inflating the middle ear through a catheter. 

Death in these cases was probably caused by suffocation 
from submucous emphysema, due to the air having been 
forced beneath the mucous membrane, the surface of which 
had been abraded by the extremity of the catheter. The oc- 
currence of emphysema need not of necessity be followed by 



13° 



PHYSICAL EXAMINATION. 



serious results, although the symptoms which supervene are 
always alarming to the patient, and may be disturbing to the 
operator. When this accident occurs, the air may either be 
absorbed spontaneously, or, if the emphysematous area is ex- 
tensive, the condition may demand relief by surgical interfer- 
ence. Puncture of the tissues suffices to evacuate the air and 
to relieve the symptoms at once. It should be stated, how- 
ever, that if even ordinary care is used in catheterization, em- 
physema will never be produced, and one who can not intro- 
duce the Eustachian catheter without abrading the mucous 
membrane of the naso-pharynx had better not introduce it at 
all. The only possible excuse for the accident would be cathe- 
terization immediately after the introduction of the Eustachian 
bougie ; therefore it should be the invariable rule never to in- 
flate the middle ear at once after the passage of such an in- 
strument. 

Occasionally, inflation of the tympanum, either by Polit- 
zer's method or by the introduction of the catheter, is followed 
by immediate dizziness, due to the sudden disturbance of laby- 
rinthine pressure. No judgment can be formed beforehand 
concerning the likelihood of this occurrence. It is always 
well when the procedure is conducted for the first time to 
begin the inflation very gently, allowing but little air to enter 
the tympanum at first, and gradually increasing the strength 
of the current if unpleasant symptoms do not supervene. 
The dizziness, which is sometimes so severe that the patient 
falls from the chair and becomes unconscious for a moment, is 
terrifying, but not dangerous. Where the membrana tym- 
pani is very thin, either as a result of a previous inflammatory 
process with the subsequent formation of cicatricial tissue, or 
from atrophic changes, a forcible inflation may rupture it. It 
follows, therefore, that the use of Politzer's method or cathe- 
terization should be preceded by an inspection of the drum 
membrane. 

The Comparative Value of Politzerization and Catheter- 
ization. — Having now considered these two methods of forc- 
ing a current of air through the Eustachian tubes and into the 
middle ear, a few words as to their relative value may not be 
out of place. As a means of diagnosis, inflation by the catheter 
is always preferable, as it enables the surgeon to estimate the 
force necessary to propel the air through the canal, to observe 
the effect upon the auscultation sounds resulting from varia- 



CATHETERIZATION COMPARED WITH POLITZERIZATION. 13! 

tions in the strength of the air current, and to repeat the ex- 
periment as often as he may desire. Moreover, success or 
failure in accomplishing the end lies entirely in the hands of 
the operator if the catheter is employed, while when the air 
bag is used by Politzer's method, the success or failure lies 
quite as much with the patient as with the surgeon, as it de- 
pends upon his ability completely to close the nasopharyn- 
geal space by elevation of the soft palate. 

In the adult the auscultatory sounds are so weak when Po- 
litzer's method is used that very little information is gained 
by using the diagnosis tube. In children under twelve years 
of age, however, the Eustachian canal is quite short, and its 
calibre comparatively large in proportion to its length. At 
this age catheterization is somewhat difficult, while the air bag 
fitted with a proper nose piece usually opens the tube per- 
fectly, and the sounds produced within the tympanum are suf- 
ficiently strong to be perceived through the diagnosis tube. 

As a diagnostic measure, then, Politzer's method should 
be used in young children and in those cases where the nasal 
passages are obstructed to such an extent that the introduc- 
tion of the catheter is well-nigh impossible. 

As a therapeutic measure the catheter is decidedly supe- 
rior to Politzer's method, allowing as it does the inflation of 
either ear without disturbing the organ of the opposite side 
and permitting the application of various medicated vapors 
directly to the membrane of the tube and tympanum, without 
bringing them in contact with the mucous membrane of the 
nasal cavity. 

When Politzeration must be employed from necessity, the 
action of the air may be confined to one ear by the insertion 
of the finger into the opposite meatus, thus compressing the 
air in the canal and rendering any appreciable outward dis- 
placement of the membrana tympani impossible. The ad- 
vantage of catheterization, mentioned in comparing the two 
methods for diagnostic purposes, holds good in this connec- 
tion as well — that catheter inflation allows an exact gradua- 
tion of the force employed, the bulb being pressed more or 
less strongly as indicated by the freedom with which the 
air passes into the middle ear. The objection so frequently 
raised against catheterization — that the instrument inflicts a 
certain amount of traumatism on the structures against which 
it impinges — need scarcely be mentioned. It is quite true 



I 3 2 PHYSICAL EXAMINATION. 

that harsh catheterization always docs more damage than 
good, but harsh catheterization is never to be employed, for, 
as before stated, the exercise of care will enable even the be- 
ginner to introduce the instrument without inflicting any in- 
jury, even if he is not successful in directing the instrument 
into the pharyngeal orifice of the tube. 

The Examination of the Nose, Naso-pharynx, and Phar- 
ynx. — Under no circumstances should the surgeon consider 
his physical examination complete until he has inspected the 
regions above mentioned which, by their anatomical position, 
exert a powerful influence upon the ear both in health and in 
disease. 

As the mucous membrane lining the nasal cavities and the 
naso-pharyngeal space is continuous with that lining the mid- 
dle ear, an intimate relation exists between the nerve and 
blood supply of the two regions, rendering the ear particu- 
larly susceptible to reflex disturbances depending upon some 
intranasal exciting cause, as well as to circulatory changes 
from alterations in the blood and lymph current within either 
the nasal chambers or the pharyngeal vault. After a satis- 
factory otoscopic examination has been made, the next step 
should be to inspect the oral cavity by means of reflected 
light, observing the condition of the mucous membrane in 
the mouth ; the presence of carious teeth ; the appearance of 
the posterior pharyngeal wall, whether it is dry or moist ; 
whether it presents the smooth, velvety appearance of a nor- 
mal mucous membrane, or is studded here and there with 
irregular elevations, indicative of the presence of small lymph 
nodules just beneath its superficial epithelial layer In this 
connection attention need scarcely be called to the importance 
of observing those two large masses of lymphoid tissue situ- 
ated between the pillars of the fauces — that is, the faucial ton- 
sils. Under normal conditions the tonsils do not project be- 
yond the faucial pillars, and special effort must be made to see 
them in a condition of perfect health, by crowding the ante- 
rior faucial pillar against the lateral wall of the pharynx, or 
turning the head of the patient first to one side and then to 
the other, to permit the observer to look obliquely across the 
cavity of the mouth, in order that they may be brought into 
view\ Any projection of these bodies beyond the pillars of 
the fauces constitutes an abnormity. 

The vault of the pharynx next demands investigation. In 



EXAMINATION OF THE UPPER AIR PASSAGES. 



133 



very young- children posterior rhinoscopy is impossible, and 
here resort may be had to digital examination. In this pro- 
cedure the mouth of the patient should be held open by a cork 
inserted far back between the jaws, or better by the use of a 
mouth gag. The index finger, with the palmar surface down- 
ward, should then be introduced into the opposite angle of the 
mouth. It should then be passed rapidly along the dorsum 
of the tongue until it meets the posterior pharyngeal wall, 
when, by quickly turning the palmar surface upward, it is 
passed behind the soft palate into the naso-pharyngeal space, 
the palate yielding readily to gentle but firm traction. By 
drawing the finger forward the nasal septum should now be 
recognized and followed upward until the roof of the cavity 
is felt. The sensation imparted to the examining digit should 
be observed: whether the membrane is soft and spongy, in- 
dicative of the presence of an abnormal amount of lymphatic 
tissue, or whether it differs but little from the sensation im- 
parted by the mucous membrane covering the posterior wall 
of the oro-pharynx. These facts having been determined, the 
tip of the finger is turned first to one side and then to the 
other, and easily appreciates the Eustachian prominences, 
after which it is withdrawn ; by sweeping along the posterior 
wall of the naso-pharynx in making its exit, the presence of 
any abnormal amount of lymphoid tissue in this location is 
determined. 

The presence of adenoid tissue in the vault of the pharynx 
affects the ear in two ways. If the mass is large, by direct 
pressure upon the Eustachian orifice the supply of air in 
the tympanic cavity may be disturbed. This fact will be ap- 
preciated by reference to Fig. 50. It is evident that the en- 
larged pharyngeal tonsil, seen in this drawing, lies so closely 
to the posterior lip of the tube that any increase in volume 
would interfere with the patency of the canal. Any slight in- 
crease in volume of the mass will close the lumen of the tube, 
after which the intratympanic air is gradually absorbed by 
the blood which circulates through vessels in the walls of 
the cavity. With each act of swallowing, at which time the 
tube opens momentarily, the air is aspirated into the naso- 
pharynx, the tube closing so quickly that the passage of air 
into the tympanum does not take place. In this manner a 
passive congestion of the mucous membrane of the middle 
ear is produced, a condition which constitutes practically the 



134 PHYSICAL EXAMINATION. 

first stage of an inflammation, and, if long- continued, results 
in permanent tissue changes. 

I am inclined to think the more important manner in 
which adenoid growths, especially those of moderate size, 
affect the organ of hearing is by the obstruction to the ve- 
nous return current from the tympanum and labyrinth. It 
must not be forgotten that the pharyngeal tonsil constitutes 
nothing more than a lymphatic gland, and, in virtue of its 
presence, may exert sufficient pressure to partially obstruct 
the venous flow from the tympanic cavity. Any condition 
which affects, for a considerable period, the circulation within 
the middle ear, will also cause a disturbance of the labyrin- 
thine circulation from an alteration in the tension of the fluid 
contained. Such changes in the labyrinth, however slight, 
render this portion of the economy particularly susceptible to 
inflammation, either as the result of infection or of mechan- 
ical irritation, the most fruitful source of the latter being the 
crowding inward of the ossicular chain by atmospheric pres- 
sure, when the tension of the air within the tympanum is re- 
duced. Evidence is not wanting, from a clinical point of 
view, that even in very early life the labyrinth may be af- 
fected by the presence of growths of this kind. We not un- 
commonly find instances of tubal catarrh in children in whom 
these growths are present ; instead of presenting, upon func- 
tional examination, the reactions characteristic of the affec- 
tion, these cases show a diminution of bone conduction, and 
sometimes a hypersesthetic condition of the auditory nerve, 
both of which phenomena indicate an irritative lesion of the 
labyrinth. In very young children it is of the utmost impor- 
tance to determine the presence or absence of a growth of 
this kind, even where the history seems to show that the child 
is entirely deaf, for, as articulate speech is acquired simply 
by imitation, an impairment of audition which in an adult or 
in a child of a few years of age would be practically insig- 
nificant, in a child so young that the function of audition has 
never been exercised, may give rise to all the symptoms usu- 
ally found in a deaf-mute. 

The oro-pharynx and the pharyngeal vault having been 
examined in the manner stated, attention should next be di- 
rected to the anterior nares. The nasal cavity should be 
inspected by anterior rhinoscopy, the tip of the nose being 
tilted up by means of the thumb of the left hand, the fingers 



EXAMINATION OF THE UPPER AIR PASSAGES. 



135 




of the hand resting upon the forehead for support, while the 
nasal orifice is dilated gently with a self-retaining speculum 
(Fig. 54). The patient's head should be flexed slightly for- 
ward, in such a position that the floor of the nasal cavity will 
be nearly horizontal. When the light from the head mirror 
is directed into the cavity 
the observer inspects first 
the inferior meatus, and 
remarks if any deformity 
of the septum is present, 

1 , • . ., , Fig. 54. — Bosworth's nasal 

determining its extent, na- IJ speculum. 

ture, and location, as well 
as the size, shape, and color, of the inferior turbinated body ; 
whether it is turgescent and occludes the inferior meatus to a 
considerable extent, or whether its mucous membrane is of 
the normal light rosy tint, and its rich venous plexuses are 
not abnormally engorged. Under normal conditions, where 
no deformity of the septum exists and the turbinated tissue is 
not swollen, the observer can readily see the posterior wall of 
the naso-pharynx by anterior rhinoscopy, and, in fact, the au- 
thor has found this one of the most simple methods of deter- 
mining the presence of hypertrophied lymphatic tissue in this 
region. This portion of the examination is rendered more 
complete if a weak solution of cocaine is sprayed into the an- 
terior nares, before an attempt is made to inspect the naso- 
pharynx in this manner. The anaethesia this produces renders 
it the simplest possible procedure to add to our information 
by touching the various parts under inspection with a cotton- 
tipped probe passed through the anterior nares. The inspec- 
tion of the lower meatus and naso-pharynx having been com- 
pleted, the head is now tilted backward, and the observer di- 
rects his attention to the upper part of the nasal chamber. In 
the anterior portion the eye recognizes readily the tip of the 
middle turbinated body, which, normally, is of a somewhat 
lighter color than the lower turbinate and less freely supplied 
with venous channels, for which reason its mucous membrane 
seems to be more closely applied to the bony framework, the 
entire structure projecting less into the lumen of the passage 
than does the inferior turbinate. Any deviation from this 
normal appearance should be carefully noted as constituting 
a source of obstruction to nasal respiration. It should be re- 
membered that the furrow or hiatus beneath the middle tur- 



136 PHYSICAL EXAMINATION. 

binated body contains the opening of the frontal, anterior, 
ethmoidal, and maxillary sinuses ; consequently it should be 
inspected with special care for the presence of a purulent dis- 
charge which, when lying here, is almost pathognomonic of 
an inflammation of one of these accessory cavities. This also 
is the region from which nasal polypi most frequently take 
their origin, and the possible presence of these growths must 
always be borne in mind during this stage of the examination. 

We have spoken only of the hypertrophic condition, since 
this is the lesion usually presented in cases which come under 
the observation of the otologist. It must be remembered, how- 
ever, that precisely the opposite state of affairs may constitute 
a morbid condition — that is, instead of an hypertrophy of the 
lining membrane, this may be abnormally thin, the turbinated 
bodies lying close to the outer wall of the passage and project- 
ing but little into the lumen. When the condition is extremely 
well marked, they are discernible with some difficulty. Under 
these circumstances the mucous membrane, instead of being 
moist, has a dry, glazed appearance, while in the sulci be- 
tween or beneath the turbinated bodies, large greenish-yellow 
crusts are seen. These result from the inspissation of the nasal 
secretion, which, owing to the atrophy of the lining mem- 
brane, is wanting in fluidity. The naso-pharynx also, instead 
of showing the presence of lymphatic tissue, may appear 
glazed, and may be covered, to a greater or less extent, with 
a thick, tough mucus, usually in the form of a scale or shell, 
which spreads irregularly in all directions from the median 
line. This naso-pharyngeal condition is seldom found before 
the age of twenty, and is usually due to retrograde changes in 
the lymphoid tissue of the region, which in early life had un- 
doubtedly been moderately but not excessively hypertrophied. 
Instead of disappearing completely after the age of puberty, 
as is often the case, interference with this retrograde process 
occurred for some reason, with the result that the fibrous 
elements of the pharyngeal tonsil persisted and increased in 
density, while the cellular elements disappeared. This local 
condition constitutes the lesion in the cases of so-called naso- 
pharyngeal catarrh, or chronic naso-pharyngitis. The ap- 
pearance described can be recognized both by the anterior 
rhinoscopic examination, and by posterior rhinoscopy as well. 

By posterior rhinoscopy we are enabled to obtain a view 
of those structures which are hidden from direct inspection 



EXAMINATION OF THE UPPER AIR PASSAGES. 



137 



by the curtain of the soft palate. This is accomplished by 
means of a mirror introduced into the mouth, with the reflect- 
ing surface directed upward, so that the image of the region 
in question is reflected in the mirror. In order to conduct 
this examination the patient is seated facing the surgeon, the 
arrangement of the light and the relative positions of the pa- 
tient and operator being the same as those already given un- 
der the description of otoscopy. The head of the patient is 
inclined very slightly forward so that the hard palate lies in 
the horizontal plane. The surgeon now depresses the tongue 
with the tongue depressor held in the left hand, crowding the 
organ downward while, at the same time the instrument is 




Fig. 55. — Bosworth's tongue 
depressor. 





Fig. 56. — Folding tongue depressor. Fig. 57. — Ttirck's tongue depressor. 

rotated slightly by elevating the handle, the blade resting 
upon the incisor teeth, thus exerting slight forward traction. 
In this way efforts at retching on the part of the patient are 
avoided, as the base of the tongue, instead of being crowded 
into the throat, a circumstance which always results in ex- 
citing an effort of deglutition, is drawn forward out of the 
pharynx. The patient is directed to breathe quietly, and 
at an opportune moment, when the palatal muscles are re- 
laxed and the velum hangs vertically downward, the rhino- 



138 



PHYSICAL EXAMINATION. 



scopic mirror, previously slightly warmed over the lamp, is 
carried rapidly into the mouth and made to assume a position 
to the one side or the other of the uvula. The rays of light 
from the head mirror are directed upon the surface of the 
rhinoscopic mirror, which, as the inclination of its polished 
surface is about one hundred and thirty-five degrees, directs 
the rays impinging upon it into the retronasal space. At first 



Fig. 58. — Rhinoscopic mirror. 

the handle of the mirror should be carried slightly downward, 
which brings into view the posterior margin of the nasal sep- 
tum ; this should be followed upward until its narrow edge is 
seen gradually to broaden and finally to disappear in the upper 
wall of the naso-pharynx. In bringing the septum into view 
the presence of an hypertrophied posterior extremity of either 
lower turbinated body will easily be recognized by its marked 
encroachment upon the lumen of the corresponding posterior 
nasal orifice. In the same manner myxomatous growths, 
springing from the nasal cavities and extending into the naso- 
pharyngeal space, will also be easily discovered. Any in- 
crease in the lymphatic tissue near the pharyngeal roof will 
be at once evident, as its presence renders it impossible for 
the observer to follow the outline of the septum upward to 
where the divergent edges are lost in the pharyngeal roof 
the expanded portion of the septum being concealed by the 
hypertrophied lymphatic tissue. By gradually elevating the 
handle of the mirror the entire roof and a portion of the 
posterior wall of the naso-pharynx are brought into view, 
and by rotation of the mirror upon the long axis of the shank 
each lateral wall of the cavity is inspected and the prominent 
posterior lip of the Eustachian tube upon either side easily 
recognized. Behind this we observe the fossa of Rosenmiil- 
ler, while in front is the orifice of the Eustachian tube, which 
varies in shape from a slitlike depression, to an opening with 
distinctly circular borders. (Figs. 49-51.) 

Preparation of Instruments. 

Before concluding the subject of the physical examination, 
a few words will not be out of place concerning the care of 
instruments used in conducting the examination. Too much 



PREPARATION OF INSTRUMENTS. 



139 



stress can not be laid upon the necessity of absolute asepsis. 
All metal instruments should be sterilized by boiling in a two- 
per-cent sodium-bicarbonate solution before each examina- 
tion. If rubber catheters are to be used, each patient should 
possess his own instrument, while if silver catheters are used 
they should be sterilized in the manner above described. 

In cleansing- the ear with a syringe, an aseptic solution or, 
better still, an antiseptic solution should always be employed. 
A solution of bichloride of mercury in the proportion of 1 to 
5,000 is sufficiently antiseptic to prevent infection of the tym- 
panic cavity if the drum membrane is accidentally perforated 
during the process of cleansing the canal. The tip of the ear 
syringe should be boiled immediately before use, or, if this is 
not convenient, the extremity should be covered by a small 
piece of soft-rubber tubing, which is renewed each time the 
syringe is used. 

As the prolonged boiling of tempered instruments is inju- 
rious, these may be thoroughly cleansed with cotton and then 
dipped for a moment in the boiling soda solution, after which 
they are immersed in a five-per-cent solution of carbolic acid 
for several minutes. 

It is scarcely necessary to call attention to the necessity 
of personal cleanliness on the part of the operator, and yet 
perhaps this is occasionally forgotten. 

These measures have been recommended by many writers 
to avoid specific infection chiefly. In this country, where 
specific disease is not as common as upon the Continent, the 
above precautions are scarcely necessary for this purpose, 
but they are necessary to prevent purulent infection of the 
middle ear. 

If the above precautions are adopted in every case, the 
extent to which operative procedures within the middle ear 
can be carried is surprising. In no region of the body, per- 
haps, is asepsis more important, and nowhere certainly has 
it been so utterly disregarded. 

The History. 

A very important part in the intelligent investigation 
of any affection of the ear, involving a partial loss or per- 
version of its function is the general history of the patient, 
together with an exact account of the aural affection. It 
is scarcely necessary to give more than briefly the various 



140 PHYSICAL EXAMINATION. 

subjects which should be investigated, before any decided 
opinion is given as to the nature of the affection or the prob- 
able course which it will pursue. These facts influence our 
opinion not only as to the favorable or unfavorable progress 
of the disease, but in no small degree enable us to determine 
the relative value of the various data with which our physical 
and functional examinations furnish us. The age of the pa- 
tient, the occupation, and the habits of life should be first con- 
sidered. The history of any previous illness must be investi- 
gated with great care, particularly concerning the occurrence 
in childhood of any of the exanthemata and other kindred 
diseases, and later in life of any of the continued fevers. A 
not unimportant factor is the presence of an hereditary taint 
— tuberculous, specific, gouty, or rheumatic — as well as the 
existence of chronic aural disease in any other members of the 
family. The habits of the patient regarding the use of opiates, 
stimulants, tobacco, indulgence in the luxuries of the table, 
or the fact of his having been called upon at any time to 
undergo severe mental strain or physical exertion, must also 
receive consideration. Special attention should also be paid 
as to whether, at any period of life, it has been necessary for 
him to take continuously large doses of the various drugs which 
are known to have a specific action on the auditory organs. 

Next the statiis prcesens should receive attention, particu- 
larly with reference to the digestive system, and here it must 
not be forgotten that the mouth is responsible for quite as 
much aural disturbance as the stomach, and inquiry should 
be made into the condition of the teeth. Any previous or 
present condition referable to the pelvic organs must also be 
inquired into. Much information may frequently be obtained 
by observing the general behavior of the subject in respond- 
ing to the various questions, it being remembered that, in 
patients of a decidedly neurotic tendency, care must be ob- 
served in the interpretation of the apparent results obtained 
by a functional examination, the mere fact that they are under 
examination often disturbing them to such a degree that their 
answers are entirely untrustworthy. 

When we come to the special history — that is, that part 
which bears directly upon the aural affection for which they 
seek advice — the length of time which this has existed must, if 
possible, be determined. It is of special importance to inquire 
into the condition of the ears in childhood, as not infrequently 



THE HISTORY. 



141 



the patient may neglect to state the presence of aural symp- 
toms in early life, conceiving that as these have apparently 
disappeared, they can have no bearing upon the present 
affection. The symptoms upon which the patient lays most 
stress generally, are impairment of hearing, tinnitus, discharge 
from the ear or pain in this location. Nausea, vertigo, general 
headache, etc., may have a very important bearing upon the 
malady, yet may be referred by the patient to entirely differ- 
ent causes and hence remain unmentioned unless he is ques- 
tioned especially with reference to their previous existence. 
If the affection has been of long duration it is of the greatest 
importance to discover whether the progress has been unin- 
terrupted, or whether under certain conditions it has been 
aggravated. In this connection the effect upon the ear of an 
acute inflammatory condition of the mucous membrane lining 
the nose or naso-pharynx, or of an aggravation of already ex- 
isting catarrhal disturbances, is to be discovered, the intimate 
relation between the upper air tract and the organ of hearing 
rendering this of great moment. It may be taken as an almost 
invariable rule where the aural symptoms are intermittent 
in character, becoming more severe when the patient surfers 
from a cold in the head, that even if the pathological process 
is located in the middle ear, our treatment must be directed 
quite as much to the upper air passages as to the tympanum 
itself in order to obtain permanent benefit. 

If the prominent symptom is an impairment of hearing or 
the presence of tinnitus we should discover under w T hat con- 
ditions these are most troublesome — whether the patient hears 
better in a noisy or in a quiet place ; whether the chief diffi- 
culty is that it is impossible to understand general conversa- 
tion, or whether the impairment is so marked that even dia- 
logue is impossible. Ascertaining the particular time during 
the day when the disturbance is most severe — whether in the 
morning, after a refreshing night's sleep, or at the end of the 
day, when tired both physically and mentally — may often aid 
us in forming our opinion. A word of caution should be 
added lest the physician may, by attaching too much impor- 
tance to any one symptom, cause the patient to exaggerate it 
unduly. This is especially true in questioning him concern- 
ing his tinnitus. If distressing, he will complain of it without 
interrogation, but if this is not the case, only the most casual 
mention should be made regarding its presence. 



CHAPTER IV. 

FUNCTIONAL EXAMINATION. 

As the aural surgeon is consulted most frequently on ac- 
count of either impairment or perversion of function in the 
auditory apparatus, it would seem natural that he could arrive 
at the most perfect conception of the condition of this appa- 
ratus by testing the functional condition of the organ of hear- 
ing. It is strange, however, that while much attention has 
been paid to the observation of physical changes in the ex- 
ternal and middle ear, which may be noted by ocular inspec- 
tion, the functional examination has ordinarily been conducted 
in the most superficial manner. 

By recalling the remarks made under Physiology, it will 
be remembered that the ear perceives not only the intensity 
of a sound, but also its pitch or quality ; consequently a 
functional examination is complete only when it estimates 
both the qualitative and quantitative condition of audition. 

I. Quantitative Tests. — In order to determine how much 
the quantitative function of the ear is impaired, it is only 
necessary to compare the distance at which any given sound 
is heard by the ear under examination, with the distance at 
which it is perceived by the normal ear. 

For convenience, the hearing power is ordinarily ex- 
pressed as a fraction, the denominator of which represents 
the distance in feet or inches at which the sound is normally 
heard, while the numerator designates the distance at which 
the sound is perceived in the affected ear under examination. 

It should be borne in mind that as a single sound excites 
only one part of the perceptive apparatus, an ear which may 
be perfectly healthy otherwise may fail to perceive one sound 
on account of the destruction of this particular area in the 
cochlea, and in order to apply this test we must be certain 
that the perceptive mechanism will respond to the particular 
standard sound to be employed as a unit. In order that the 

(142) 




QUANTITATIVE TESTS. 143 

results of various observers may be compared, use must also 
be made of a sound of a given quality and intensity ; and 
herein lies one of the chief difficulties of comparing the re- 
sults of tests made by different observers. 

The sound most commonly employed in making a quanti- 
tative test, where the hearing is but moderately impaired, is 
the tick of the watch. While this may be fairly accurate in 
observations made by the same individual, it is manifestly 
impossible that any comparison of results reached by several 
examiners can be made. To obviate this difficulty, Politzer* 
devised the instrument shown in Fig. 59, which is supposed 
to produce a sound whose intensity and quality are always 
the same. This, perhaps, is the most uni- 
versally used apparatus for conducting 
experiments of this kind. The chief ob- 
jection is that as the sound produced by 
the instrument is heard by the normal 
ear at a distance of forty-five feet, its 
use is restricted "to those cases in which 

. . f . . Fig. 59. — Politzer s acou- 

the impairment of hearing is considera- meter. 

ble. Moreover, it is not impossible that 

the particular portion of the perceptive apparatus which is 
responsive to this sound may be so affected that, while the 
function of the organ as a whole may improve, the distance 
at which this sound is perceived may remain unchanged. 

The ideal test in estimating impairments of audition is 
the human voice, since the patient desires especially that 
the power of audition for sounds thus produced shall be im- 
proved, and, moreover, because his own estimate of the prog- 
ress of his disease is very largely based upon the ease or diffi- 
culty with which he is able to understand the human voice 
in ordinary conversation. Therefore, no matter what me- 
chanical appliance may be used in estimating the power of 
audition, no system of examination is complete which fails to 
record the facility with which various vocal sounds are per- 
ceived. Since the conversational voice varies greatly both 
in pitch and intensity in different individuals, an exact com- 
parison of the results obtained by using the conversational 
voice as a standard would be difficult. The whisper, how- 
ever, is fairly constant in pitch and intensity, if care be taken 

* Archiv fiir Ohrjnheilkunde, vol. xii, p. 104. 



144 FUNCTIONAL EXAMINATION. 

that in every examination the whisper shall be as loud as 
possible, or what may be termed " a forced whisper." The 
examiner in carrying out this test should first fill the lungs by 
a forced inspiration, and then allow them to empty them- 
selves by a normal expiratory effort, after which he should 
repeat in a whispering voice the particular word or words to 
be used as the test. I have taken pains to compare the data 
obtained, by various observers by tests conducted in this 
manner, and find that the error of experiment is very small 
when the test is conducted carefully. It should be remem- 
bered that the patient soon becomes familiar with sentences 
used in these experiments, and when the same phrases are 
repeated frequently the results obtained are worthless. To 
avoid this result, Siebenmann* advises the use of numbers of 
two figures. In this way the patient can not become familiar 
with any given test sentence, as the same numbers are not 
repeated on successive examinations, or if repeated, their se- 
quence is changed. We meet, however, with the difficulty 
that certain combinations of letters are more easily perceived 
than others, even when whispered with the same intensity — 
in other words, each vowel and consonant sound possesses an 
intensity peculiar to itself, the vowel sounds being more eas- 
ily heard than consonant sounds. This characteristic of indi- 
vidual letters is denominated their logographic value, and the 
appended table, prepared by Blake, exhibits the relative in- 
tensity of the consonant sounds ; the T sound being that of 
the greatest intensity, its value for purposes of comparison is 
denominated in the table as ioo: 



T = ioo 


B = 53 


K = 3« 


Z= 63 


D = 45 


L = 21 


C= 62 


S = 40 


N= 11 


p= 58 


F=35 


M= 9 


G= 56 







If proper care is exercised in the selection of numbers of 
two figures, or if the numbers are selected at random, and 
the average results of ten experiments be taken as represent- 
ing the quantitative value of the hearing in any particular case, 
a fairly accurate estimate of the condition may be obtained. 

Instead of estimating the distance at which a sound of 

* Archives of Otology, vol. xxii, p. 1. 



QUANTITATIVE TESTS. I45 

known intensity is heard, another fairly accurate method 
consists in comparing the time during" which a given musical 
note is perceived by the defective organ, with the perception 
time of the normal ear. The sounding body is set in vibration 
by a constant force, and the relation is expressed in the form 
of a fraction of which the normal perception time is the de- 
nominator and the perception time of the defective ear ex- 
amined is the numerator. While not absolutely accurate from 
a mathematical point of view, the error is so slight that it 
may be practically disregarded, as proved by the experiments 
of Bartfi.* The only difficulty in testing in this manner is in 
obtaining a constant force for setting the tuning fork or any 
other convenient instrument in vibration. If each examiner 
determines his own standard experimentally, by estimating 
the time during which the fork is heard by the normal ear, it 
being set in vibration by a blow which habit has enabled him 
to make fairly constant, a comparison of such results will be 
perfectly possible and fairly accurate, it being only necessary 
that the rate of vibration, or the pitch, of the instrument be 
known, and that its note be pure — that is, free from over- 
tones. The note usually employed is that of a tuning fork 
making five hundred and twelve V. S., which corresponds to 
the treble C of the musical scale, as it is more easy to con- 
struct an instrument of this pitch, free from overtones, than 
one of lower pitch. 

It is scarcely necessary to mention the more complicated 
instruments which from time to time have been devised for 
determining quantitative audition. Their use has never be- 
come universal on account of their complex construction. 
The phonograph, supplied with a series of standard cylin- 
ders and capable of reproducing sounds which shall always 
be uniform both in pitch and intensity, is probably the most 
simple of these devices. The principle of the telephone has 
been used in constructing instruments for this purpose. Of 
these, probably that recommended by Urbantschitsch f is the 
best. The operation of this instrument and of other kindred 
devices depends upon gradually diminishing the intensity of 
a given sound by sliding the secondary coil of an induction 
apparatus, introduced into the circuit, over the primary coil. 

* Archives of Otology, vol. xvii, p. 153. 
f Lehrbuch der Ohrenheilkunde, Vienna, 1890, p. 39. 
11 



I 4 6 ' FUNCTIONAL EXAMINATION. 

The sound is conveyed to the ear of the patient by means of 
an ordinary telephone. 

In the instrument shown in Fig. 60 the sound employed is 
produced by the rapid interruption of the electric current by 
Neef's hammer. It is necessary that the vibrating hammer 
be completely inclosed, in order that its repeated blows may 
not be heard through the air in cases where the hearing is 




Fig. 60. — Urban tschitsch's electric acoumeter. JS t Primary battery ; JV, Neef's ham- 
mer for interrupting the current automatically, and thus producing the sound to 
be employed in conducting the test ; 2, 2', Induction coils of equal size, but 
wound in opposite directions ; 1, Movable helix ; T, Telephone ; S, Screw for 
moving the helix. As the helix is withdrawn from one secondary coil, it enters 
the other, which is wound in the opposite direction, and the intensity of the 
sound heard through the receiver is thus increased or diminished at will. (Ur- 
bantschitsch.) 

but slightly impaired, or by the opposite ear, where there is 
great impairment upon one side, the opposite organ being 
normal or nearly so. 

A somewhat similar instrument has been devised by Gran- 
dinego * in which the source of sound is a metal rod producing 
a pure musical note corresponding to C in the musical scale. 

* Handbuch der Ohrenheilkunde von Schwartze, Leipzig, 1893, vol. ii, 
P- 383. 



QUANTITATIVE TESTS. i 4 y 

This certainly possesses advantages over the instrument just 
described, in which the quality of the sound must vary con- 
siderably. 

The maximal phonometer was devised by Lucae * to meas- 
ure the intensity of a vocal sound by observing to what extent 
the vibrating column of air displaced a diaphragm upon which 
it was made to impinge. The instrument is too complicated 
to be used universally. 

Whatever method is adopted in making a quantitative test, 
certain precautions must be taken to avoid error in cases 
where a marked impairment of hearing exists in one ear, with 
only a very slight impairment in the function of the other. 
It is impossible to prevent the normal ear from perceiving 
sounds of great intensity, no matter how tightly the external 
auditory canal is closed, and as a preliminary step to the ex- 
amination it is essential that the test sound employed shall 
act upon the organ under examination alone. 

We begin, then, by placing the patient in such a position 
that the ear to be examined is turned toward the source of 
sound ; the opposite meatus is tightly closed by the finger 
of the patient or, better still, by that of an assistant. To se- 
cure perfect occlusion the digit should be previously mois- 
tened with water. When the hearing is impaired to a great 
degree and we have reason to doubt the efficiency of this 
method of excluding sound from the opposite ear, at the con- 
clusion of the examination of the affected ear, both external 
auditory canals should be closed and the examination re- 
peated. If now the patient hears equally well with both 
canals closed, it is evident that the affected ear exerted no in- 
fluence upon the results obtained by the first tests — in other 
words, that the ear upon this side is totally deaf. If, how- 
ever, the results are not the same, the hearing power upon 
the affected side is obtained by subtracting the perception 
distance obtained by the last experiment from that elicited by 
the first. 

It is possible, under certain conditions, to convey the sono- 
rous vibrations to the affected ear through a tube, the sound- 
ing body being removed to a distance sufficient to prevent 
perception by the organ of the opposite side. This is par- 
ticularly valuable if the method is adopted of estimating the 

* Archiv fur Ohrenheilkunde, vol. xii, p. 282. 



148 



FUNCTIONAL EXAMINATION. 



hearing power by comparing interval during which the sound 
is perceived, with that of the normal ear. 

II. Qualitative Tests. — We recall that the normal ear per- 
ceives vibrations as musical notes repeated at regular intervals 
from 16 V. S. to about 32,500 V. S. These, 
then, may be called the lower and upper 
limits of audition, respectively. When the 
organ is functionally perfect these limits 
vary but slightly. When, however, either 
the perceptive or transmitting mechanism is 
the seat of a pathological process, these lim- 
its are changed in a characteristic manner. 

To complete our functional examination, 
then, it is essential to be provided with some 
convenient device for producing the lower 
notes of the musical register — that is, from 
16 to 20 V. S. to 64 V. S. per second — and 
also some instrument which will emit the 
shrill, high-pitched sound, caused by im- 
pulses following each other with extreme 
rapidity. The first requisite is easily ob- 
tained through the medium of a tuning fork 
of large size. If provided with clamps, a 
single instrument may, by altering the posi- 
tion of these, be made to vibrate at varying 
rates. The fork shown in Fig. 61 answers 
this purpose fairly well. When the clamps 
are fastened at the extremity of the branches 
of the fork the instrument makes about 26 
V. S. When a little care is exercised in set- 
ting the fork in vibration, this note is prac- 
tically pure and is easily perceived as a mu- 
sical sound. When the clamps are moved 
down, so that about half the length of each 
clamp extends beyond the free extremity of 
the arm of the fork, as shown by the dotted 
lines in Fig. 61, the rate of vibration increases 
to about thirty per second. When carried 
still lower, the note corresponds very nearly to the contra C 
of the musical scale. If the clamp is entirely removed the fork 
emits a pure note corresponding to the next octave higher ; 
in other words, it makes sixty-four vibrations per second. 




FlG. 61. — The au- 
thor's tuning fork 
for determining the 
lower tone limit. 
The instrument is 
provided with ad- 
justable clamps. 



QUALITATIVE TESTS. I 49 

While this device does not by any means allow us to ex- 
amine the lower portion of the scale as thoroughly as we may 
desire, it reveals very quickly any deficiency in audition for 
the lower notes of the scale. 

The Galton whistle affords a simple means of producing 
the higher notes of the musical scale, for determining the up- 
per tone limit. This apparatus is essentially a closed organ 
pipe in which the column of air is set in vibration, either 
through the medium of the expired air, by holding it between 
the lips, or, better still, by means of a rubber ball fitted to 
its open extremity. By a well-known law of physics, if the 
diameter of a tube is uniform, the note produced by forcing 
air through it will become higher and higher as the length of 
the tube diminishes. Thus, if the length is diminished one 
half, the resulting note w T ill be an octave higher than the funda- 
mental tone of the original tube, and by decreasing the length 
of the tube gradually, all of the various musical notes may 
be obtained between the fundamental tone of the tube and 
that emitted by a pipe of infinitesimal length. 

The length of the tube is reduced by a metal obturator, 
which is slowly advanced along its lumen through the agency 
of a screw ; the outer surface of the tube is graduated, each 
division of the vertical scale representing the space traversed 
by the obturator during a single complete rotation of the 
screw. 

Owing to the fact that so many of the instruments sold 
are not made according to a fixed rule, the graduations of the 
scale can not be employed in comparing the results obtained 
by examination with different instruments. It has seemed 
wise, therefore, to state here briefly the means by which the 
number of vibrations per second which any instrument of this 
kind produces may be determined. 

The Galton whistle acts as a closed organ pipe, and the 
variation in pitch of the notes produced depend upon the phys- 
ical rules which govern the construction of wind instruments 
of this class. By the law of closed tubes the length of the 
tube producing a given note is one quarter the wave length. 
Without going into detail, it will be sufficient to state that in 
any instrument of this character the number of vibrations per 
second may be calculated by dividing the velocity with which 
sound travels by four times the length of the closed tube. 
Sound travels through the air, at the average temperature, at 



150 FUNCTIONAL EXAMINATION. 

the rate of eleven hundred and eighteen feet per second ; this 
number, divided by four times the length of the tube which 
produces the note in question, will give the rate of vibration. 
In other words, the result obtained by dividing eleven hun- 
dred and eighteen feet by the length of the tube, is equal to 
four times the number of vibrations producing the funda- 
mental note of the tube. 

A more exact method of determining the upper tone limit 
is by means of a series of rods, known as Koenig's rods. 
These small steel cylinders are of various lengths, the diam- 
eter of each being the same. To elicit the primary note of 
one of these rods it is suspended by means of loops of very 
light wire or of silk thread, from points equidistant from the 
two extremities of the cylinder, the location of the points 
of support being determined by certain mathematical laws. 
These cylinders are set in vibration by a small metallic ham- 
mer and emit a pure tone, the pitch of which varies with the 
length of the cylinder. This method of determining the 
upper tone limit is probably more exact than that in which 
the Galton whistle is used, but it is much more tedious, and 
for clinical purposes yields scarcely better results. 

By the low-pitch tuning fork and the Galton whistle we 
may determine the limits between which musical notes are 
perceived. Bezold * advises a more exhaustive investigation, 
and has devised a series of forks and organ pipes by which 
the complete series of musical notes between the limits of 
audition can be produced. As the employment of such a 
number of instruments in examining each case involves the 
expenditure of considerable time, their use must be confined 
to the investigation of particular cases, in which so exhaustive 
a test seems necessary. 

The value, as a diagnostic measure, of the next test to be 
applied depends upon the fact that, under normal conditions, 
sound waves impress the perceptive centres by the transmis- 
sion of the sonorous impulses to the labyrinth through the 
medium of the conducting mechanism — that is, through the 
external auditory meatus, the tympanic membrane, and the 
ossicular chain. As a matter of habit, all sounds are best 
perceived through this avenue, under normal conditions. If, 
however, the conducting mechanism is obstructed, be the ob- 

*Arch. fur Ohrenheilk., vol. xxx, p. 283. 



BONE CONDUCTION— WEBER'S TEST. 



151 



struction in the canal, in the tympanic membrane, or within 
the middle ear itself, this path along which the sound waves 
normally pass is closed to a greater or less degree, depending 
upon the completeness of the obstruction. Under these con- 
ditions, the vibrations must reach the end organ of the audi- 
tory nerve by some other path, as, for example, the solid 
structures of the cranium ; and under these conditions a vi- 
brating body held in contact with the cranial bones produces 
a greater impression upon the auditory centres — that is, is 
heard more loudly — than when held in front of the external 
auditory meatus. It is to be remembered that under normal 
conditions also, when a sounding body is brought into con- 
tact with the bones of the skull, the vibrations are perceived. 
The period during which the sound is heard, however, is 
much less than the interval during which it is perceived 
when held before the auditory canal. Roughly speaking, the 
duration of air conduction is about double that of bone con- 
duction, the air conduction being relatively somewhat greater 
for the higher notes — that is, a little more than twice that of 
bone conduction — and the bone conduction, on the other 
hand, slightly greater for the lower notes of the scale, or a 
little more than half that of air Conduction. Again, the very 
highest notes are scarcely heard by bone conduction under 
normal conditions, while the very low notes of the register 
are felt rather than heard, when the instrument producing 
them is brought in contact with the head. Age also influ- 
ences the power of bone conduction, which becomes much 
reduced after the age of forty-five or fifty years. 

Having learned the history of the malady, and determined 
the physical condition of the ear in the manner previously 
detailed, and having arrived at a conclusion concerning the 
extent of impairment by the functional examination, the next 
step should be to locate the pathological condition either 
in the sound-conducting or the sound-perceiving apparatus. 
Many of the methods employed for this purpose bear the 
names of the investigators who first demonstrated their value. 
The test most commonly spoken of is that of Weber, who, as 
the result of a series of investigations, found that when a vi- 
brating tuning fork was placed upon the skull in the antero- 
posterior vertical median plane and the meatus of one side 
was closed, the sound of the fork was heard more strongly in 
the ear which was occluded. In the same way if the struc- 



IC2 FUNCTIONAL EXAMINATION. 

tures of the middle ear were bound down by adhesions, if the 
cavity was filled with fluid, or if the ligamentous tissues were 
so relaxed that the weight of the drum membrane and the 
attached ossicular chain constituted an obstruction to the 
passage of sonorous vibrations from the external canal to the 
parts beyond — under all of these conditions the vibrating tun- 
ing fork was heard better in the obstructed ear. The deduc- 
tion was inevitable that, in a case in which impairment of 
hearing existed upon one side alone, or in which impairment 
existed on both sides to an unequal degree, the perception of 
the tuning fork from the median line of the head would be 
stronger in the ear in which the pathological condition in the 
conducting mechanism was more marked. In other words, 
the fork would be better perceived by bone conduction in the 
poorer ear. If the organ upon one side was normal, the fact 
of the fork being heard better in this ear would locate the 
pathological condition of the opposite side in the perceptive 
rather than in the transmitting apparatus. 

The second classical test was devised by Rinne,* who was 
the first to determine that the normal ear perceived a vibrat- 
ing tuning fork, held before the canal, for about twice as long 
a time as when the shank of the fork rested upon the mastoid 
process. In cases where the canal was occluded, or where an 
obstructive lesion was present within the tympanum, it was 
found, after the fork had ceased to be heard in front of the 
ear, that its vibrations could still be recognized when the 
handle of the instrument was brought in contact with the 
mastoid. In applying this method of investigation then, if, in 
a given case in which the hearing is impaired, the duration of 
bone conduction is greater than that of air conduction, the in- 
ference would be that the impairment is due to some lesion 
of the conducting apparatus, and, pathological conditions of 
the canal being excluded by physical examination, the loca- 
tion of the morbid process must of necessity be the tympanic 
structures. If, on the other hand, the hearing is impaired 
and the normal relation between bone and air conduction is 
preserved, although both are found to be reduced, the seat 
of the disease must be the perceptive portion of the organ of 
hearing. 

While both of these facts are of undoubted value, the 

* Prager Vierteljahresschrift, 1855, vol. i, p. 71, vol. ii, pp. 45-155- 



RINNE'S TEST. 



153 



accumulation of clinical evidence from the investigation of a 
large number of cases, has convinced those interested in Otol- 
ogy that in many instances they can not rely absolutely upon 
these reactions to indicate the site of the lesion. 

The first fact with which we are impressed in a careful 
reading of these experiments is that very little attention seems 
to have been paid to the pitch of the fork used in conducting 
the tests. From what we know by experiment (see Physi- 
ology) of the effects of increase of tension in the intratympanic 
structures, or the weighting of these parts or of the tympanic 
membrane, it can easily be seen that if the impairment of 
hearing is very slight and the fork used in making the test is 
of moderately high pitch, an absolute reversal of the relation 
between the bone and air conduction may not take place, 
since the application of a load to the drum membrane or 
ossicles interferes principally with their vibration in their re- 
sponse to the lower notes of the scale. This fact is recog- 
nized by Lucas and by Bezold,* the latter restricting the ap- 
plicability of Rinne's experiment to those cases in which the 
whispered voice is not understood at a distance greater than 
three and a half feet. It must be remembered, that in arriv- 
ing at this conclusion regarding the application of Rinne's 
test, a tuning fork making about 512 V. S. was used. By the 
use of forks of lower pitch the test becomes applicable to cases 
in which the degree of impairment is much less than this. 
It is seldom wise, however, to determine bone conduction 
with a fork of lower pitch than 128 V. S., since a fork lower 
than this is felt rather than heard, and comparatively few 
patients are able to distinguish between the two sensations. 
If a fork making 512 V. S. is used in cases where the impair- 
ment is slight, instead of looking for an absolute reversal of 
the relation between bone and air conduction, a comparison 
should be made between the time during which the fork is 
heard when held in front of the canal and that during which 
it is perceived when placed upon the mastoid. It will be 
found that bone conduction is increased relatively, although 
Rinne's test will be positive. Such a result is called " a di- 
minished positive." For clinical purposes, however, it would 
be impossible to conduct the test in this manner, as the dura- 
tion periods would then need to be determined with great 

* Allg. Wien. med. Ztg., 1887, p. 183. 



154 FUNCTIONAL EXAMINATION. 

exactness, and reliable results could be obtained only by 
complicated apparatus. 

Following in this same line, Schwabach * has found that 
where obstruction exists in the conducting mechanism, the 
absolute period of bone conduction exceeds that of the 
normal ear. Pomeroy,f in applying this test insists upon the 
ears being tightly stopped with the fingers. In other words, 
he compares the maximum bone conduction to be obtained 
from the normal ear with that to be elicited from the organ 
under examination, combining really the test of Schwabach 
with that of Weber. 

The determination of the absolute bone conduction in sec- 
onds, not only consumes considerable time, but the result 
obtained must vary w T ith the age of the patient, and with dif- 
ferent examiners. The variations in the force of the blow 
setting the fork in vibration also constitute a source of error. 
It is much simpler, if the examiner possesses a normal ear, to 
follow the plan suggested by Gardiner Brown,J who con- 
ducts the test as follows: The tuning fork is set in vibration, 
and the handle is held against the mastoid of the patient 
until the sound is no longer heard, this fact being communi- 
cated to the examiner by the patient raising his hand. The 
handle of the fork is then applied to the mastoid of the ex- 
aminer, and if he perceives the sound, it is fair to assume that 
the bone conduction of the patient is below the normal stand- 
ard. If, on the contrary, he no longers hears it, the inference 
is that the bone conduction is normal. For general purposes, 
the data obtained in this manner are sufficiently exact, when 
taken in connection with results arrived at by applying the 
other tests for determining the location of the lesion. 

Reviewing briefly the facts stated in the preceding pages, 
it will be seen that lesions of the conducting mechanism are 
characterized by — 

I. A loss or impairment of audition for the lower notes 
of the scale, and as the degree of impairment of hearing in- 
creases, the lowest note which can be perceived, or the lower 
tone limit, as it is called, becomes elevated. 

II. The relative duration of bone conduction as compared 



* Zeitschrift fur Ohrenheilkunde, vol. xiv. 

f Diseases of the Ear, New York, 1883, p. 337. 

X Lennox Browne, The Throat and its Diseases, London, 1S87, p. 535. 



DIFFERENTIAL DIAGNOSIS. 



155 



with air conduction increases, the inversion of the ratio being 
more marked for the lower notes of the scale and affecting 
these first, the change occurring with the higher notes in 
proportion as the pathological condition increases, and conse- 
quently as the impairment of function becomes more marked. 

III. Lesions of the conducting apparatus interfere very 
slightly with the perception of the highest notes of the scale 
by air conduction — in other words, have very little effect upon 
the upper tone limit. 

In the same manner diseases of the receptive mechanism 
are characterized by — 

I. No elevation of the lower tone limit. 

II. No change in the normal relation between the duration 
of bone conduction as compared with air conduction, the 
absolute duration of both, however, being reduced. 

III. Absolute deafness for certain notes of the scale, 
usually in its upper portion, thus frequently lowering the 
upper tone limit. This is almost invariably the case when 
the condition is secondary to changes within the tympanum. 

Our plan of functional examination, then, is essentially as 
follows : 

The quantitative determination of the hearing by means of; 

a. The watch, if the impairment is slight. 

b. The acoumeter, if the degree of impairment is more 
marked. 

c. The determination of the hearing distance by means of 
the "forced whisper" by making use of numbers of two 
figures. 

The qualitative determination of the hearing : 

a. The determination of the lower tone limit, using for 
this purpose the fork already described, illustrated in Fig. 61. 
The record shows the lowest number of vibrations perceived 
by the patient as a musical note, the different rates of oscilla- 
tion being obtained by changing the position of the clamps 
as already explained. 

b. The determination of the upper tone limit by means 
of the Galton whistle, recording the highest number of vibra- 
tions perceived by the patient as a musical sound. 

c. The determination of absolute bone conduction. 

In determining the absolute bone conduction in any given 
case the rate of vibration of the tuning fork, as has already 
been stated, must be taken into account. In patients under 



i 5 6 



FUNCTIONAL EXAMINATION. 



forty years of age the most convenient fork to be employed 
is one tuned to the note " C," making five hundred and twelve 
double vibrations per second. In patients over forty, a fork 
making two hundred and fifty-six double vibrations per second 
gives the most accurate results. For the benefit of those who 
do not care to make a special study of aural diseases, and 
hence to whom a multiplicity of devices for determining the 
actual functional condition of the ear is rather objectionable, 
it may be well to enumerate the instruments with which satis- 
factory work can be done. 

In the first place, it is necessary to be provided with a low- 
pitched tuning fork, such as the one shown in Fig. 61, fitted 
w T ith clamps, by means of which the rate of vibration can be 
changed by altering their position upon the limbs of the fork. 
The highest note obtainable with this instrument is one of 
sixty-four vibrations per second. This instrument will enable 
the observer to determine defects in the transmission of the 
lower notes of the scale, a condition which is characteristic of 
the lesions of the conducting apparatus. It may not be possi- 
ble for him to determine the lower tone limit, as it may lie 
above the highest note obtainable with this fork ; but if the 
lower tone limit lies above 64 V. S., the inference must be 
that the sound-conducting apparatus is not in a normal con- 
dition. For the determination of the upper tone limit the 
observer must be provided with a Galton whistle. The modi- 
fied form, devised by the author and shown in Fig. 62, gives 
a greater range than the original instrument of Galton, and is 




Fig. 62. — The author's modification of the 
Galton whistle. 



preferable when only a limited number of tuning forks are 
at hand. This whistle enables tests to be made through a 
compass of from about sixteen hundred and seventy-seven vi- 
brations per second to about forty thousand vibrations per 
second, the increased length of the instrument augmenting 
the compass ; it thus supplies the place of the higher tuning 
forks. 

For the determination of bone conduction, if but one in- 
strument is to be used, the C fork, making $12 V. S., is the 



INSTRUMENTS. 



157 



Ik 



best for general use, since its construction is comparatively 
simple, and overtones interfere but little with its primary 
note. The instrument (Fig. 63) devised by Blake, and mak- 
ing 256 V. S., is also exceedingly well adapted to this pur- 
pose. In this fork the overtones are avoided by increasing 
the weight of the branches at their free ex- 
tremities. With these three instruments a 
fairly accurate functional examination can 
be made, and the deductions drawn from 
the data thus obtained will scarcely ever be 
misleading. A more extended examination 
will simply confirm, in most instances, the 
opinion already formed as the result of the 
investigation with the above limited num- 
ber of instruments. It is of advantage, of 
course, to have appliances at hand for the 
production of all the notes of the musical 
scale, and Bezold * has devised a series of 
tuning forks and of wind instruments which 
produce musical notes on the principle of 
a closed organ pipe, and by which the in- 
vestigator can obtain any note of the scale 
between the high and low limits of audition. 
The series consists of eight tuning forks, 
two organ pipes, and one Galton whistle. 
Even for a very exhaustive investigation 
of any case it is scarcely necessary to multiply the arma- 
mentarium to this extent, since by means of the low fork 
already mentioned, together with the modified Galton whistle 
and the series of five forks recommended by Hartmannf (Fig. 
64), perfectly satisfactory work can be done. 

Each of the five forks in this set is tuned to the note C ; 
the lowest fork making one hundred and twenty-eight vibra- 
tions per second, while the highest registers two thousand 
and forty-eight vibrations per second, each fork being tuned 
an octave higher than the one below it. This particular range 
is chosen as it includes those fundamental notes which may 
be called essential to perfect audition — that is, the range of 
notes employed in ordinary conversation. In addition, the 



Fig. 63. — Blake's tun- 
ing fork. The rate 
of vibration indi- 
cated on the handle 
(512) refers to single 
vibrations. 



* Archiv fiir Ohrenheilk., vol. xxx, p. 283. 
f Krank. des Ohres, Berlin, 1889, p. 32. 



58 



FUNCTIONAL EXAMINATION. 




Fig. 64. — Hartmann's series of tuning forks. 



Galton whistle will enable an investigation as to the power 
of the patient to perceive those notes of the scale lying above 

the highest fork of the 
Hartmann series. I have 
employed these instru- 
ments for some time, and 
have seldom been misled 
in the deductions made 
from the results thus ob- 
tained. 

In making these quali- 
tative tests certain pre- 
cautionary measures are 
necessary : for example, 
to avoid the production 
of overtones in using the 
large tuning fork with 
the clamps so placed as 
to produce the lowest 
obtainable rate of vibra- 
tion — that is, twenty-six vibrations per second. If care is 
not taken, an overtone will be produced when the fork is 
struck, and this may be perceived by the patient to the ex- 
clusion of the very low primary note of the fork. In every 
instance, therefore, the observer should make certain by hold- 
ing the vibrating fork for a moment before his own ear be- 
fore it is used to test the patient, that the primary note alone 
is elicited. It must also be remembered in testing air con- 
duction with tuning forks, that the fork may be held in front 
of the ear in such position, that its note will not be perceived, 
on account of the interference of the sound waves, which 
completely neutralize each other and cause absolute silence. 
This phenomenon depends entirely upon certain physical 
facts, as pointed out long ago by Weber.* That this inter- 
ference may take place the fork is held so that either of the 
four angles of the parallelogram inclosed by the branches 
is directed toward the meatus. During the complete rota- 
tion of the fork upon its long axis, therefore, there will be 
four periods during which the note is heard, alternating with 
four periods of complete silence. It is hardly necessary to 



* Die Wellenlehre, Leipzig, 1825, p. 506. 



PRECAUTIONARY MEASURES. 1 59 

say, in conducting the functional examination, that care must 
in any case be exercised that each of these positions is avoided. 
Urbantschitsch * has also demonstrated that when the vibrat- 
ing fork is carried toward the ear from before backward it is 
not heard as it passes the anterior and posterior margins of 
the meatus, and the same phenomenon is observed as it passes 
the superior and inferior boundaries of the meatus, if carried 
from above downward. 

In testing absolute bone conduction it often happens that 
the patient confuses the feeling of vibration communicated by 
the instrument to the cranial bones with the perception of the 
tone which it produces. This is particularly true when forks 
of low pitch are employed in making tests, and in cases of al- 
most absolute deafness. The first error can be avoided by 
using a fork of higher pitch, the second by bringing the vibrat- 
ing fork in contact with some other portion of the body, as, 
for instance, by pressing the handle upon the elbow or knee, 
and questioning the patient as to whether the sensation is ex- 
actly the same as when the instrument is applied to different 
parts of the cranium. If it is, it naturally follows that he has 
confused the tactile sensibility with the auditory sense, and 
his statements are consequently unreliable. 

It should also be remembered that the feeling of vibration 
is much more marked when the handle of the fork is slender 
than when it is of considerable thickness, and this should be 
borne in mind in selecting an instrument for testing bone 
conduction. 

In using the Galton whistle the instrument is held close 
to the entrance of the canal and the current of air is so regu- 
lated as to produce the most perfect musical note obtainable 
with the scale in any given position. Here the individual 
tested may not distinguish between the blowing sound pro- 
duced by the air and the high-pitched musical note which he 
should hear. If the length of the tube is increased so that a 
distinct whistle is at first heard and then gradually reduced 
by advancing the obturator by turning the screw, thus pro- 
ducing notes successively higher in pitch, he will easily dis- 
tinguish the point at which the whistling sound disappears 
and the blowing or puffing sound is heard. If the screw is 
then turned in the opposite direction until the whistling 

* Lehrb. der Ohrenheilk., Vienna, 1890, p. 37. 



160 FUNCTIONAL EXAMINATION. 

sound is again perceived, a reading- of the scale will give the 
true upper tone limit. Further, the patient should be made 
to describe the character of the sound in his own words and 
without any suggestion on the part of the surgeon, as the 
latter can easily infer from the reply, whether the impression 
is that of a musical note or simply the blowing due to the 
current of air. 

It would seem, therefore, a matter of no great difficulty to 
make a fairly accurate differentiation between diseases of the 
sound-conducting and sound perceiving-apparatus. We meet 
with a large class of cases, however, in which both portions 
of the auditory organ are at fault, the perceptive apparatus 
being secondarily affected as the result of pathological condi- 
tions in the sound-conducting mechanism. Here, then, the 
results obtained by the above tests may be confusing. In 
order, therefore, to interpret correctly the data obtained from 
such an examination, it is necessary to inquire somewhat 
closely into the causes which are operative in the production 
of the phenomena already described. 

It is conceded that the augmentation of bone conduction 
in pathological conditions of the meatus and middle ear which 
cause an obstruction to the passage of sonorous waves inward, 
is due to the fact that it prevents the passage of undulations out- 
ward from the ear when the vibrating body is brought in con- 
tact with the cranial bones in the same manner as it offers a 
barrier to their propagation in the opposite direction when the 
source of sound is held near the meatus. Steinbruegge * con- 
siders that the absolute or relative increase in the bone con- 
duction in these cases is due to a condition of hyperesthesia 
of the auditory nerve resulting from the mechanical irritation 
to which its terminal fibres are subjected. While this condi- 
tion of increased irritability may be present in many cases, it 
is certainly not the cause of the increased bone conduction 
in most instances, other symptoms of auditory hypersensitive- 
ness being wanting in many cases. Further, an examination 
of the condition of the auditory nerve by means of the gal- 
vanic current fails to support Steinbruegge's hypothesis. 

Gradenigof has shown that lesions of the conducting ap- 
paratus do in some instances cause the auditory nerve to re- 



* Archives of Otology, vol. xvii, p. 117. 
f Arch, fur Ohrenheilk., vol. xxvii, p. I. 



IRREGULAR PHENOMENA. ^i 

spond more easily to the galvanic current than under normal 
conditions; and this fact should be remembered, as it enables 
us to interpret results, which would otherwise seem contra- 
dictory, obtained by functional examinations in certain cases. 

The experiments of Siebenmann * demonstrate that an 
increase in the labyrinthine pressure prolongs bone conduc- 
tion, as evidenced by an examination before and after Val- 
salva's inflation (the latter procedure, as is well known, in- 
creasing the tension of the labyrinthine fluid). In cases 
where the membrana tympani had been destroyed the laby- 
rinthine pressure was increased by pressing the head of the 
stapes inward by means of a probe. 

We should expect, therefore, to find a prolongation of the 
interval during which the tuning fork is heard when brought 
in contact with the cranial bones, in all cases where speculum 
examination shows either a depressed drum membrane, or the 
presence of adhesions within the tympanum, drawing the 
ossicular chain toward the inner tympanic wall. This is usu- 
ally the case, but occasionally we find that the reverse is 
true. The latter condition can be explained upon the hy- 
pothesis that the condition of increased tension has lasted so 
long that the function of the auditory nerve has been, to a 
certain extent, ablated by the mechanical pressure, and that 
the case is no longer one of intratympanic disease pure and 
simple, but that an actual pathological condition is present 
within the labyrinth, dependent upon the disturbance within 
the middle ear. 

When the intratympanic changes are comparatively sud- 
den, as in cases of simple congestion and oedema of the 
Eustachian tube with displacement of the drum membrane 
and of the entire ossicular chain inward, we observe that, in 
addition to an augmentation of bone conduction, the upper 
tone limit is usually considerably lowered. This is easily 
explainable when we remember that the highest notes of the 
scale are perceived by the lowest portion of the cochlea. 
This portion of the labyrinth, lying as it does in immediate 
relation to the foot plate of the stapes and the membrane of 
the round window, will be easily affected not only by changes 
in the position of the base of the stapes and of the membrana 
tympani secondaria, but also by circulatory disturbances 

* Arch, of Otol., vol. xxii, p. I. 



1 62 FUNCTIONAL EXAMINATION. 

within the tympanum. It is not strange, therefore, that the 
very highest notes of the scale should be no longer heard 
when any sudden change of position takes place in the ossi- 
cular chain, or when the tympanic mucous membrane be- 
comes engorged with blood, interfering with the motility of 
the ossicles. If the interference with the function of the 
cochlea depends simply upon a slowly increasing pressure, 
the equilibrium of the labyrinth is but slightly disturbed, 
owing to the direct communication of both the endolymphic 
and perilymphic spaces with the lymph channels within the 
cranial cavity. In such cases, therefore, very little disturb- 
ance of the upper tone limit is observed, although the intra- 
tympanic structures may be completely bound down by adhe- 
sions and drawn inward toward the external labyrinthine 
wall. The channels of communication, however, between 
the labyrinthine and intracranial lymphatic spaces are so 
narrow, that any sudden increase of pressure causes a dis- 
turbance of equilibrium in the labyrinthine fluid, and hence 
lowers the upper tone limit. It is wise, in view of this inti- 
mate association between the labyrinth and the tympanum, 
to repeat the qualitative tests after a restoration of the nor- 
mal air pressure within the tympanum by inflation, to guard 
against all possibility of error. 

In addition to the tests given above, mention should be 
made of certain other methods of investigation which lie at 
our disposal in making a differential diagnosis. Among the 
most important of these are the following : 

Bings* Experiment. — This test, first described by the 
above-named author, is essentially a modification of Weber^s 
experiment. It is conducted as follows: A vibrating tuning 
fork is applied either to the forehead or vertex in the median 
line, and is held in this position until its note is no longer 
perceived. If at this moment the finger is inserted into the 
external auditory canal of either side, the note of the fork 
will again be heard. This second interval during which the 
fork is perceived is called the period of secondary perception 
for the tone. If the conducting apparatus is normal this sec- 
ondary perception interval is well marked ; while if its dura- 
tion is shortened, the presence of some obstructive lesion of 
the conducting mechanism may be inferred. If the interval 



* Wien. med. Blatter, 1891, No. 41. 



GELLE'S TEST. 



163 



of secondary perception is of normal duration, while at the 
same time there is an interference with the auditory appara- 
tus, as evidenced by subjective or objective symptoms, the 
conducting- mechanism must be in a normal condition, and 
the seat of the morbid process must lie within the labyrinth in 
the auditory nerve or be due to changes within the cerebral 
hemispheres or medulla. 

Gelle's Test. — Gelle * proposes to test the mobility of the 
ossicular chain, and especially of the stapes, by compressing 
the air in the external auditory meatus and observing the 
effect upon the perception of the note of a tuning fork in con- 
tact with the skull. If the foot plate of the stapes is movable, 
with each condensation of air within the meatus the sound of 
the fork becomes much diminished in intensity or may be lost, 
reappearing again as the pressure is relieved. The condensa- 
tion is effected by means of a small air bag provided with a 
flexible rubber tube, the free extremity of which carries a 
conical tip which can be inserted air-tight into the canal. If 
the labyrinth is affected, either primarily or secondarily, the 
tone will also be diminished, but the increase in pressure will 
produce a sense of dizziness and sometimes tinnitus. 

Rohrerf considers this test valuable when taken in con- 
nection with Rinne's test. According to his investigations, 
when Rinne's experiment was negative Gelle's test yielded a 
negative result in seventy-three per cent of the cases tested 
and a positive result in but twenty-three per cent. When 
Rinne's test was positive Gelle's test yielded negative results 
in twelve per cent and positive results in eighty-eight per 
cent of the cases examined. 

The patients selected in these experiments of Rohrer's 
were cases in which the hearing was very much impaired — so 
much, in fact, as to make it more than probable that a laby- 
rinthine lesion co-existed with the pathological process within 
the tympanum. Rohrer lays particular stress upon the value 
of Gelle's experiment in determining the secondary involve- 
ment of the labyrinth following an inflammatory process 
within the middle ear, in w T hich case Rinne's test very fre- 
quently yields negative results ; if Gelle's test gives negative 
results as well, the inference that the labyrinth is affected is 



* Tribune medical, Oct. 23, 1881. 

f Lehrb. der Ohrenheilk., Vienna, 1891, p. 66. 



164 FUNCTIONAL EXAMINATION. 

fully warranted. In cases where the hearing- is very much 
impaired and Rinne's test is positive, Gelle's test is also usually 
positive, if the labyrinth is affected. 

Itelbergs Test. — Another experiment, calculated to differen- 
tiate between lesions of the labyrinth and those of the middle 
ear, is that of Itelberg.* It depends upon the principle that 
a nerve continuously irritated by any one stimulus becomes 
fatigued after a certain time and performs its function less 
readily. It follows, therefore, that when the perceptive tract 
is in an abnormal condition this effect will be produced more 
readily than in a state of perfect health. In performing the 
test a large tuning fork is made to vibrate in front of the ear 
for a period of fifteen or twenty minutes, the instrument be- 
ing set in vibration repeatedly by as nearly as possible the 
same initial force as soon as its oscillations become weak. If 
after the nerve has been subjected to this continuous stimulus 
the perception interval has not been much shortened, the re- 
ceptive apparatus is assumed to be in a normal condition. As 
the value of this test depends greatly upon the intelligence 
of the patient, its application is somewhat limited. A much 
simpler demonstration of auditory fatigue is constantly pre- 
sented, in cases where prolonged testing with sounds which 
are of a similar character as, for instance, the watch, acoumeter, 
or the whisper yield results which differ greatly from each 
other, and the ability to perceive the sound steadily decreases 
as the patient becomes fatigued. We often note a similar con- 
dition of the nerve in what may be termed the persistence of 
an auditory impression ; for instance, in testing a patient with 
the watch it will often be stated that the sound is heard either 
after the watch has been stopped or has been removed to such 
a distance that it is impossible for the sound to be heard. 
This depends upon the fact that an impression once made 
upon the auditory centres is retained by them for a longer 
period than normal, demonstrating the fact that they are no 
longer in a state of health. 

Gradenigd s Test. — Gradenigo f finds in cases in which the 
acoustic nerve-trunk is affected that it quickly loses its power 
of reacting to sonorous stimuli if the quality of the sound 
remains unchanged. In other words, the nerve is quickly 



* Wien. med. Presse, 1887, No. 10. 

f Ilandbuch der Ohrenheilk. Von Schwartze, Leipzig, 1893, vol. ii, p. 403. 



GRADENIGO'S TEST. 



I6 5 



fatigued. If, however, it is allowed to rest for a short time, 
it is again able to perform its function. The simplest method 
of practicing this test is by the use of a tuning fork of about 
fifteen hundred or two thousand vibrations per second as the 
source of sound. Such a fork is perceived from fifty to sev- 
enty seconds under normal conditions. In cases of torpidity 
of the auditory nerve, if this fork is set in vibration and held 
close to the ear its note ceases to be audible after a much 
shorter interval. If it is now removed a short distance from 
the ear, for a few seconds, and again carried close to the 
meatus, it will be again perceived. This manoeuvre may be 
repeated several times during one period of vibration of the 
fork. It seems that the auditory nerve when in this condition 
is easily fatigued, but after an interval of rest it may react 
to a weaker stimulus than that which failed to excite it after 
it had been subjected to that one for a certain time. 

Gradenigo * asserts that when the auditory nerve trunk is 
involved the interference with function is particularly marked 
for the tones of the middle portion of the scale, the very high 
and very low tones being well perceived. 

In all of these tests, dependence must be placed upon the 
statements of the patient, and much of the accuracy must de- 
pend upon the intelligence and the correctness with which 
he answers questions. Methods have been devised to avoid 
the necessity of introducing this element of error in deter- 
mining the location of the morbid process. Thus Lucaef 
conducted an exhaustive series of experiments with an instru- 
ment which he termed the interference otoscope. The device 
consisted of a tuning fork, the vibrations of which were main- 
tained at a constant amplitude by the action of the electric 
current. The fork was placed so that its vibrations were 
collected by a funnel-shaped receiver, the smaller end of 
which was prolonged as a flexible tube terminating in three 
branches. One of these terminal divisions was inserted into 
each external auditory meatus of the patient, while the third 
was inserted into either auditory canal of the examiner. It is 
thus seen that the vibrations of the fork would be conveyed 
through the tubes to both ears of the patient and to the ear 
of the examiner as well. Any obstruction in the sound-con- 



* Op. cit., p. 395. 

f Arch, fur Ohrenheilk., vol. iii, p. 186, 



1 66 FUNCTIONAL EXAMINATION. 

ducting apparatus, as we know, renders the transmission of 
vibratory impulses more difficult in proportion to the degree 
of obstruction, and, as the sound perceived by the examiner 
represents not only the vibrations coming directly to his ear 
— from the fork — but also the waves reflected from the ears 
of the patient, it would be possible, by alternately closing 
the tubes upon the one side and the other, to estimate any 
variation in the intensity of the sound thus produced. It is 
evident that the sound would be more intense in proportion 
as the transmitting mechanism offered an obstruction to the 
inward progress of the impulses. In other words, the more 
intense sound should come from the poorer ear if the conduct- 
ing apparatus alone were affected. Great care must be taken, 
in conducting this test, that the tubes of the binaural stetho- 
scope shall be exactly equal in length, and also that the ear- 
pieces shall fit the meatus exactly, in order that all of the 
reflected waves may pass backward through the tube and into 
the ear of the examiner. This test has been somewhat modi- 
fied by Jankau * in the following manner : 

A vibrating tuning fork is placed upon the vertex of the 
patient and the receiver is dispensed with, while the auscul- 
tation tube of the examiner terminates in a Y tube, the free 
extremities of which join the tubes occluding the external 
canals of the patient as in the other instrument. Under these 
conditions the tone conveyed to the ear of the examiner is 
re-enforced by the action of the external meatus, which acts 
as a resonator, augmenting the sound of the fork. Under 
normal conditions, both ears being the same, there is no ob- 
struction to the vibrations through the cranial bones to the 
labyrinthine fluid, from which they are communicated to the 
ossicular chain, to the membrana tvmpani, and in turn to the 
air in the canal, which re-enforces the sound by its action as 
a resonator. If, however, an obstruction, due to an increased 
tension of the labyrinthine fluid, exists, which prevents the 
passage of the sound waves outward from the labyrinth to 
the ossicular chain, this resonant action will to an extent be 
diminished, and the observer will perceive that the sound 
from this side is less intense. In other words, the weaker 
sound will come from the poorer ear, if the impairment of 
function is due to increased labyrinthine tension. If, on the 



* Arch, fur Ohrenheilk., vol. xxxiv, p. 190. 



GALVANIC REACTION. 



167 



other hand, the vibrations of the labyrinthine fluid are not 
impeded, but the tympanic structures external to the stapes 
are in a state of increased tension, the resonant action of the 
canal will be increased on account of the rigidity of its walls, 
the condition favoring a more perfect reflection of the sound 
waves ; in which case the stronger tone will come from the 
poorer ear. Jankau's clinical investigations and experiments 
seem to confirm this supposition. 

The difficulty of avoiding errors of experiment are so con- 
siderable here that the chief use of the procedure will be as a 
confirmatory test. 

The Galvanic Reaction of the Auditory Nerve. — As has been 
stated, the auditory nerve differs very little from other spe- 
cial or general structures of a similar nature. In the study 
of nervous diseases in general, great attention has been paid 
to the reactions of nerve tissue under electrical stimulation, 
and the changes in the electrical phenomena which morbid 
processes cause. Special attention was given by Brenner* 
to the effect produced by the galvanic current upon the audi- 
tory nerve, and he was the first to formulate the reaction of 
the normal acoustic nerve. According to this author, upon 
the application of the galvanic current, a sharp sound is pro- 
duced at the moment of cathodal closure (c. a), which, as the 
current is continued, is transformed into a continuous sing- 
ing sound (c. d.). At the moment of cathodal opening (c. o.) 
the singing ceases abruptly. Anodal closure (a. c.) produces 
no sound, and the period of silence is continued as long as 
the current passes in this direction (a. d.). Upon anodal 
opening (a. o.) a low sound is perceived similar in quality to 
that heard at cathodal closure, but of less intensity. The 
strength of the current in milliamperes represents the strength 
of the current necessary to excite the acoustic nerve. If after 
cathodal closure the current is allowed to pass for a few sec- 
onds and the circuit is then broken, it will be found that a 
current of less intensity is necessary to excite an auditory im- 
pression than in the first instance. The same follows if the 
experiment is repeated for the third time. These variations in 
the strength of the current represent the primary, secondary, 
and tertiary electric irritability of the auditory nerve. Under 



* Untersuch. u. Beobachtungen iiber die Wirkung elektrischer Strome auf das Ge- 
hororgan, Leipzig, 1868. 



1 68 FUNCTIONAL EXAMINATION. 

ordinary conditions, the nerve requires so strong a current to 
produce an auditory impression upon it, as to make it neces- 
sary to conclude the experiment before the reaction is ob- 
tained, on account of the pain which the passage of the cur- 
rent causes. The primary irritability, however, should not 
fall below six milliamperes. In conditions of hyperesthesia 
the primary irritability will be found much below this figure ; 
while in cases of torpidity of the nerve this normal limit is 
exceeded. 

In the absence of a large galvanic battery, a simple storage 
battery of from four to eight volts furnishes sufficient current 
to enable one to make all of these tests ; it is necessary to com- 
bine in the circuit a reliable rheostat and a milliampere-metre. 
The current obtained in this manner, while not of great 
strength, is ample for the purpose and. possesses the advan- 
tage of not being liable to the variations in intensity which we 
so often find when the dip cell is used. 

Some of the dry cells now offered for sale also furnish a 
convenient means for securing a reliable current with the ex- 
penditure of but a trifle. Twelve dry cells furnish a current 
sufficient for taking the galvanic reactions of the auditory 
nerve. In no instance should the ear be subjected to the 
action of the electric current for purposes of either diagnosis 
or therapeusis without including a rheostat in the circuit, by 
which its intensity can be controlled. In employing the gal- 
vanic current as a means of diagnosis it is also essential that 
a milliampere-metre be added to estimate quantitatively, the 
current causing special phenomena. 

Considerable difference of opinion exists as to the proper 
method of applying the electrodes in conducting the tests. 
According to the choice of the examiner, the electrode applied 
to the ear may be placed either upon the side of the face just in 
front of the tragus, or it may be placed over the entrance of the 
canal, which has been filled with water ; or the canal may be 
filled with water and the electrode immersed in this, care be- 
ing taken that it is insulated, so as not to come in contact with 
the walls of the meatus. The circuit is completed by means 
of a broad electrode placed upon an indifferent region, some- 
times on the back of the neck and sometimes held in the hand. 

The experiments of Gradenigo * are of considerable in- 



* Arch, fiir Ohrenheilk., vol. xxvii, p. 



GALVANIC REACTION. 



169 



terest, in that they demonstrate not only the reaction of the 
acoustic nerve to electrical stimuli, but also seem to prove con- 
clusively that auditory hyperassthesia is not the cause of the 
lateralization of the tuning fork in affections of the middle ear. 
The investigations of this writer show that while the sound 
may be referred to the hyperassthetic side, it is often lateralized 
when no hyperassthesia exists, or the sound may be referred 
to one side even when hyperassthesia exists upon the other. 

Another interesting result demonstrated by these experi- 
ments is the fact that electric stimulation of the nerve of one 
side often increases the susceptibility of the opposite nerve to 
the action of the current. 

The remarks made concerning the electric acoumeter ap- 
plies to the employment of the galvanic tests — viz., that al- 
though valuable, the method is too complicated to admit of 
general use, and the amount of additional information gained 
by it scarcely compensates for the extra time required for its 
application. We shall therefore rely principally upon the 
power of audition for lower notes, the hearing power for high 
notes, the absolute bone conduction and a quantitative deter- 
mination of the integrity of audition by means of the whis- 
per, in arriving at an opinion concerning the location of any 
lesion. To these may properly be added either Eitelberg's 
test or that of Gradenigo, to afford information concerning the 
ease with which the nervous apparatus becomes exhausted by 
prolonged stimulation as compared with the normal organ 
under similar conditions. The data furnished by these latter 
tests, however, may be frequently quite as well obtained by 
observing closely the behavior of the patient during a pro- 
longed functional examination. When the perceptive appa- 
ratus is in an asthenic condition, it will be found that pro- 
longed qualitative and quantitative tests are followed by a 
marked diminution in the ability of the patient to perceive a 
given sound, demonstrating very clearly that the continuous 
stimulation to which the nerve tissues have been subjected, 
has ablated their power to a marked extent. 

It should be remembered that under normal conditions 
excitation of the perceptive tract renders it more sensitive in 
responding to stimuli, as is clearly shown by the experiments 
of Urbantschitsch.* The statement already made in consider- 



* Archiv fur Ohrenheilk., vol. xxxiii, p. 186. 



I 7 o FUNCTIONAL EXAMINATION. 

ing- the electrical irritability of the auditory nerve is no less 
true of the response of the nerve structures to sonorous 
stimuli — that is, a sounding body allowed to vibrate before 
one ear may, to a marked degree, influence the perceptive 
power of the organ on the opposite side.* 

* Urbantschitsch, Lehrbuch der Ohrenheilkunde, Vienna, 1890, p. 417. 



SECTION II. 
DISEASES OF THE CONDUCTING APPARATUS. 



DISEASES OF 
THE CONDUCTING APPARATUS. 



I. DISEASES OF THE AURICLE. 
CHAPTER V. 

CONGENITAL MALFORMATIONS OF THE AURICLE. 

Any malformation of the external ear at birth has for a 
long time been considered somewhat indicative of the pres- 
ence of some corresponding mental impairment. That mental 
weakness, defects, or perversions often accompany such anom- 
alous anatomical conditions is a matter of experience ; that the 
two always occur together, however, is by no means true. 

Concerning the classification of these malformations we can 
divide them into : 

I. Deformities of particular parts of the auricle, the exter- 
nal ear as a whole maintaining its general outline. 

II. An anomalous shape or a malposition of the entire 
auricle, including variations in size, or in the angle of attach- 
ment to the skull. 

III. The presence of some anomalous anatomical condi- 
tion, such as certain supernumerary appendages, fistulas, etc., 
in the region of the ear, the auricle being present either in its 
normal form or being more or less altered in shape. 

IV. A condition of asymmetry between the organs of the 
opposite sides. 

Since the last group is of but little importance, it may be 
disposed of in a few words. Occasionally we find one auricle 
either very large, or, on the other hand, while normal in con- 
tour, uniformly reduced in size without any other departure 
from the normal standard. Such a condition can be looked 
upon only as a " freak of Nature," and is in no way associated 
with mental impairment, nor can any definite cause be as- 
signed for its existence in many cases. When met with in 



I 74 CONGENITAL MALFORMATIONS OF THE AURICLE. 

the adult, a careful investigation of the previous history may 
reveal some injury in childhood which had been forgotten, 
and the deformity, which at first was considered congenital, 
really depends upon a traumatic cause. 

I. Deformities of particular parts of the auricle, the ex- 
ternal ear as a whole maintaining its general outline. 

Anomalies of the Helix. — The so-called Darwinian ear and 
the satyr ear are examples of moderate anomalies of this 
character. Wagenhauser * has reported an instance in which 
the upper part of the helix was absent on both sides, while 
Stetterfand Schubert % have reported instances in which 
the helix was abnormally developed, hanging downward and 
forward as a flap. In Stetter's case the antihelix was also in- 
volved, and the deformity was so extensive as to obstruct the 
entrance to the meatus. Relief was obtained by a plastic 
operation. 

Anomalies of tJie Antihelix. — When the antihelix is strong- 
ly developed it may project beyond the line of the helix to 
such an extent as to constitute a deformity. This is most 
noticeable when the auricle is viewed from behind. Grade- 
nigo has observed this condition more frequently in females 
than in males, and considers it more common among the 
criminal and insane than among others. In a case observed 
by the author the antihelix projected fully one eighth of an 
inch above the plane of the helix, and a condition of asym- 
metry was also present, the anomalous condition being partic- 
ularly well marked upon the left side ; upon this side also 
the lobule was small and terminated abruptly at the antitragus. 
The intellect was normal. 

Sometimes an abnormal development of the superior crus 
of the anthelix pushes the helix upward and forward, giving 
rise to what is called the pointed ear. 

Anomalies of the Lobule. — The lobule is abnormally large 
in the black race, reaching such a development among the 
Kaffirs that by piercing it in a particular manner a sufficiently 
capacious cavity is formed within the lobule to serve as a 
pouch for carrying tobacco. 

Occasionally the lobule is wanting, as in a case reported 



* Archiv fur Ohrenheilkunde, vol. xix, p. 55. 

f Ibid., vol. xxi, p. 92. 

X Ibid., vol. xxii, pp. 51, 52. 



ANOMALIES OF THE TRAGUS, ETC. 



1/5 



by Binder, * while Szenes f mentions an instance in which the 
lobule was rudimentary ; there was also an absence of the ex- 
ternal auditory meatus and a faulty development of the 
corresponding side of the face. Probably the most frequent 




Fig. 65. 



-Anomalous division of the antihelix into three crura, the lower of which 
joins the crista helicis. (From a photograph.) 



deformity in this region is cleft lobule, the appearance re- 
sembling closely that seen when the lobule has been torn in 
the direction of its long axis, by the forcible removal of an ear- 
ring from the ear. 

Anomalies of the Tragus. — The tragus may extend back- 
ward and be of such size as to offer an actual obstruction to 
the entrance of sound waves into the meatus. McBride;}: has 
observed a case in which there was a rudimentary tragus as- 
sociated with other abnormities of development. 

Anomalies of the Antitragus. — Malformation here is exceed- 
ingly rare. Szenes* observed an instance in which two spurs 
of cartilage projected from the antitragus into the canal. 



*Arch. liir Psychiatrie, 1887, vol. xx, p. 2. 
f Arch, fur Ohrenheilkunde, vol. xxiv, p. 185. 
:}: Edinburgh Med. Journal, April, 1881. 
# Arch. f ,-: r Ohrenheilkunde, vol. xxvi, p. 140. 



iy6 CONGENITAL MALFORMATIONS OF THE AURICLE. 

II. An anomalous shape or a malposition of the entire 
auricle. 

This condition in its most pronounced form is commonly 
known as microtia, and depends upon an arrest or perversion 
of the process of development which results in so complete a 
malformation that the distinctive parts of the external ear are 
no longer well defined. The condition may be unilateral or 
bilateral, and is frequently associated with co-existent malfor- 
mation of the deeper parts of the auditory apparatus. For 
this reason the condition merits special attention. Microtia is 
associated in the majority of instances with a complete ab- 




Fig. 66. — Microtia. 



sence of the external auditory meatus, or, in cases where the 
canal exists, it is a rudimentary structure ; the ossicular chain 
is frequently poorly developed or absent, and an anomalous 
condition is common in the labyrinth as well. 

The deformity may not be confined to the ear alone, but 
the entire side of the face may be poorly developed. The ap- 
pearances vary greatly in different cases, and an attempt to 
describe them would be but a recital of particular instances. 
Fig. 66 is a drawing of a case observed by the author. In 
this case the left ear presented an anomalous formation of the 



MICROTIA— MALPOSITION— TREATMENT. 



177 



antihelix (see Fig - . 65), while there was well-marked microtia 
upon the right side. At birth the right ear was much more 
deformed than the picture shows it to be, the helix at that 
time being adherent by its antero-superior border to the in- 
tegument in front. The cutaneous surfaces separated sponta- 
neously a few weeks after birth. 

Treatment. — Where the deformity is but moderate an at- 
tempt at correction by a plastic operation may be made in 
early childhood. Regarding any attempt to form an artifi- 
cial meatus, the results have been so unsatisfactory that it is 
seldom desirable to operate for this purpose. If the rudi- 
mentary canal is present, its size may be increased by surgical 
measures, but the frequent malformation of the deeper struc- 
tures commonly renders the operation futile in improving the 
function of the organ. If any attempt is to be made to restore 
the patency of the canal, it should be delayed until the patient 
is old enough to give information in regard to the power of 
sound perception either through the air or through the cra- 
nial bones. The technique of the operation for re-establishing 
the meatus will be described under polyotia. The plastic 
operation on the auricle for the relief of the deformity, how- 
ever, may be done very early. When a high degree of de- 
formity is present, it seems advisable to excise the entire au- 
ricle and supply its place by an artificial device rather than 
attempt its restoration by surgical measures, which will at 
the best leave a misshapen organ. 

From a practical point of view, one of the most interesting 
conditions included in this group is that in which the angle 
between the organ and the lateral aspect of the skull is con- 
siderable. This constitutes a deformity amenable to treat- 
ment, and, especially in the female sex, one for which we are 
occasionally consulted. If noticed in infancy, or even in early 
childhood, the simplest plan for correction is to coat the pos- 
terior aspect of the auricle and the adjacent cutaneous surface 
of the head with collodion, the ear being then pressed to the 
side of the head and held in position until it adheres. If nec- 
essary, several light strips of gauze may be passed over the 
top of the auricle, holding it closely to the side of the head, 
and fastened with collodion. Persistence in this plan of treat- 
ment will usually be successful in correcting the condition. 
In adult life little can be gained by this method, and resort 
must be had to some operative measure. This is best effected 
13 



178 CONGENITAL MALFORMATIONS OF THE AURICLE. 

by removing an elliptical segment of the integument from the 
posterior surface of the auricle, the posterior incision passing 
just beyond the line of attachment to the auricle; the integu- 
ment is then dissected up from the posterior surface of the 
auricle for a sufficient distance to permit of an approxima- 
tion of the edges of the wound. Occasionally it is necessary 
to excise a segment of the cartilaginous framework as well, 
in order that the ear may be restored to the proper position. 
Usually the difficulty is sufficiently well overcome by approxi- 
mating the edges of the cutaneous wound without removing 
any of the cartilaginous framework, the tension due to the 
elasticity of the cartilage being easily overcome by the su- 
tures. Under aseptic precautions and with care, a perfect po- 
sition can be secured. General anaesthesia is usually neces- 
sary, although it is possible to perform the operation under 
local anaesthesia. It is well to operate upon the two organs 
separately, using the first as a standard to which the. other is 
made to conform. 

III. The presense of some anomalous anatomical condi- 
tion, such as supernumerary appendages, fistulae, etc., in the 
region of the ear, the auricle being present either in its nor- 
mal form or being more or less misshapen. 

Auricular Appendages, the General Form of the Ear being 
preserved. — Abnormities belonging to this class are the sim- 
plest with which we have to deal. The most frequent region 
for the appearance of supernumerary appendages is the re- 
gion of the tragus. A case of this sort occurring in my own 
practice is shown in Fig. 6j. The prominent cartilaginous 
process constituting the deformity was located just above 
the right tragus, was about three fourths of an inch in length, 
and projected forward and outward. The tragus itself could 
be felt, but was rudimentary. 

Barth* cites an instance in which a rudimentary mam- 
mary gland was located just below the lobule upon one 
side. 

A condition belonging to this class constitutes what is 
known as " fistula congenita auris" (Fig. 68). Its occurrence 
is due to an arrest in development of the auricle itself, or, as 
is believed by some, it indicates an incomplete closure of the 
first visceral cleft during fcetal life. That this is considered a 

* Virchow's Archiv, vol. xii, part iii. 



AURICULAR APPENDAGES— FISTULA. 



179 



somewhat rare malformation is probably due to the fact that 
it seldom gives rise to symptoms, and consequently many 
cases pass unnoticed. Four cases of this deformity came 
under my own observation during- a period of about a year. 
Fig. 68 represents an appearance which is fairly typical. The 
deformity may occur either upon one side alone, or it may be 
bilateral. In one of my cases the fistula was located just above 
the tragus, while in another the orifice of the tract was situ- 
ated one inch above this point and presented an opening 
about one sixth of an inch in diameter through which a probe 
could be passed downward and inward for half an inch. On 





Fig. 67. — Auricular appendage. 



Fig. 



. — Fistula congenita auris. 
(a, fistula.) 



the opposite ^ide the site of the fistula was occupied by a shal- 
low depression which did not admit even the finest probe. 
Occasionally a slight discharge exudes from the orifice of the 
fistula, and in a case reported by Pfluger* the appearance of 
a purulent discharge from such a source was always preceded 
by acute pain in the ear. Where the wails of the sinus se- 
crete, a blocking of the orifice may cause a retention cyst of 
considerable dimensions. An instance of this is cited by Ur- 
bantschitsch.f The most common location for such fistulse 
is in the vicinity of the tragus, although they are occasionally 



* Monatsschrift fur Ohrenheilkunde, 1874, No. it. 
f Lehrbuch der Ohrenheilk., third edition, 1890, p. 94. 



i8o CONGENITAL MALFORMATIONS OF THE AURICLE. 



met with in the helix and in other localities. Burnett * states 
that these fistulas may lead into the tympanic cavity. 

Treatment. — The appendages should be removed by 
means of the knife. The operation is exceedingly simple. 
When they present in the region of the tragus it is well in 
excising the growth to form a tegumentary flap from the cov- 
ering of the anterior surface of the appendage, which can be 
folded backward over the stump, bringing the line of the su- 
ture close to the entrance of the meatus, as the cicatrix is less 
visible in this position. 

Fistula congenita auris demands no treatment excepting 
in those instances where a retention cyst has been formed by 
the occlusion of the orifice of the sinus. This condition is re- 
lieved by a simple incision and the evacuation of the contents 
of the tumor, the walls being curetted with a sharp spoon to 
secure an obliteration of the cavity. 

Polyotia. — This term is applied to a congenital deformity 
in which, in addition to microtia, certain supernumerary 

growths are met with in 
the immediate vicinity of 
the ear, but entirely distinct 
from the deformed auricle. 
Occasionally they occur 
with a perfectly normal au- 
ricle, the fact that they are 
not attached to it distin- 
guishing them from the au- 
ricular appendages already 
described. The condition 
is sometimes associated with 
congenital aural fistula, as 
in the case reported by 
Biirkner.f The deformity 
may be bilateral or unilat- 
eral, and the supplementary 
organ may present a variety of shapes, the most common 
being that of a small wartlike excrescence situated upon the 
cheek in front of the external meatus. When this multiple 
deformity exists there is usually considerable variation in 




Fig. 69. — Polyotia. 



* A Treatise on the Ear, Philadelphia, 1884, p 211. 
f Archiv fur Ohrenheilkunde, vol. xxn, p. 200. 



POLYOTI A— TREATMENT. 181 

size and shape between the members of the group. As 
already stated, a normal auricle is seldom found, although 
this may be the case. The condition usually occurs in con- 
nection with microtia. An instance of this kind, observed by 
me, is depicted in Fig. 69. The auricle upon the affected side 
was represented by a cutaneous fold, beneath which there was 
a cartilaginous framework. This was bent forward upon the 
cheek, covering the normal site of the meatus. Upon the pos- 
terior surface there was a well-defined groove between the 
cartilaginous and noncartilaginous portion. About three 
fourths of an inch in front of the anterior margin of this de- 
formed auricle was a small, wartlike prominence representing 
a second and rudimentary pinna, it being situated too far ante- 
riorly to represent the tragus. The fibro-cartilaginous lamella 
already mentioned was freely movable, and just beneath its 
attachment a slight depression could be felt. It was impossi- 
ble to determine whether the external auditory meatus was 
present or not. The ear of the opposite side was normal. 

The remarks made under microtia, regarding a faulty 
development or a complete absence of the deeper portions of 
the auditory apparatus apply equally well to the condition 
of polyotia. 

Treatment*. — The small supernumerary appendages are 
usually easily removed, where they are large enough to con- 
stitute a serious deformity. The disfigurement which they 
cause is usually slight, however. For a correction of the 
larger malformed mass remaining, a plastic operation may be 
attempted, although, as in microtia, more satisfactory results 
may be expected by a complete removal of the deformed 
member, its place being supplied by an artificial substitute. 
Concerning the establishment of the meatus surgically, the 
remarks already made under microtia apply equally well 
here. Even if it is possible to construct the meatus, it is 
scarcely possible to secure a condition of permanent patency. 
When it seems desirable to attempt this operation the tech- 
nique is as follows : 

The field of operation being rendered thoroughly aseptic 
by shaving the parts and cleansing them with soap and water, 
and subsequently with ether, an incision is made just behind 
the attachment of the deformed pinna. The soft parts are 
divided, exposing the bone, after which the anterior flap, in- 
cluding the periosteum, is turned forward upon the cheek, ex- 



1 82 CONGENITAL MALFORMATIONS OF THE AURICLE. 

posing the region normally occupied by the external auditory 
canal. A thorough search must next be made for any open- 
ing in the bone which may represent a rudimentary meatus, 
and if such a channel is discovered it should be cautiously en- 
larged, by rrieans of either chisels or burs, the latter being 
propelled by an ordinary dental engine or an electric motor. 
When no fistula is present the bone may be cautiously exca- 
vated in the region corresponding to the proper position of 
the meatus. Great care is necessary during the entire pro- 
cedure, as damage may be done to important adjacent struc- 
tures. After the canal has been formed our means for secur- 
ing its patency will consist in the insertion of an aluminium or 
rubber tube, which will separate the opposite raw surfaces and 
allow the deep parts to be thoroughly cleansed, during cica- 
trization. As the anterior flap when replaced would cover 
the newly formed channel, it should be perforated over the 
orifice of the meatus by making two incisions bisecting each 
other at right angles. Four triangular flaps are thus formed, 
which are to be inverted into the orifice of the canal and 
maintained in position for the first few days by a gauze pack- 
ing, alter which the metal or rubber tube already mentioned 
is to be employed. As soon as healthy granulations spring 
up, a method which suggests itself as exceedingly feasible 
would be Thiersch's method of skin grafting, as we might 
thus hope to secure a tegumentary lining to the passage and 
prevent its contraction during cicatrization. Such an opera- 
tion should only be performed at the earnest solicitation of the 
parents, in the case of a child, or, if the patient has reached 
adult life, only after the extreme uncertainty of the result has 
been fully explained. 



CHAPTER VI. 

WOUNDS AND INJURIES OF THE AURICLE. 

It is seldom that we see incised or punctured wounds in 
this particular portion of the body, although occasionally we 
are called upon to treat deformity which has resulted from 
wounds of this character inflicted at some preceding- period. 
Here the ordinary rules of plastic surgery will enable us to 
secure satisfactory results. In performing any plastic opera- 
tion upon the auricle it is well to remember that when the 
entire thickness of the external ear is involved all sutures 
should be inserted upon the posterior surface of the organ, 
accurate approximation of the cutaneous edges being secured 
by passing the stitches deeply into the cartilaginous frame- 
work, but not bringing them out through the integument 
covering the anterior surface. 

In the treatment of lacerated wounds, which are more 
frequently met with, we should attempt to save as much tis- 
sue as possible, erring rather in this direction than in that 
of removing any part which possibly may possess sufficient 
vitality to survive. The edges of the wound should be 
thoroughly cleansed, and as a primary procedure a few sutures 
may be applied, holding the parts as nearly as possible in 
their normal position. It is a simple matter after the circula- 
tion has been thoroughly re-established to secure a more exact 
approximation and relieve whatever deformity may be present. 
As the auricle is composed so largely of cartilage, any severe 
bruising of the tissue is likely to be followed by a sharp peri- 
chondritis, and unless there is so much laceration as to contra- 
indicate the plan, it is well to anticipate such an attack by the 
employment of cold locally for the first twenty -four hours 
after the injury has been received ; subsequently proper atten- 
tion may be given to the correction of deformity. 

Contused wounds of the auricle without laceration of the 
integument are of frequent occurrence. Such an injury re- 

(183) 



1 84 WOUNDS AND INJURIES OF THE AURICLE. 

suits either in the formation of a hasmatoma — an effusion of 
blood beneath the perichondrium — or in an acute perichon- 
dritis ; in either case the appearance is almost identical. The 
injured region is occupied by a somewhat spherical tumefac- 
tion, the normal outline entirely disappearing-. Upon palpa- 
tion we discover that the contents of the tumor are evidently 
fluid. The surface varies considerably in color, according 
to the particular manner in which the injury was inflicted, 
and, to a less extent, the character of the fluid contained. If 
this is blood, the surface is of a dull deep-red color, while if 
the tumefaction is an evidence of a perichondritis, with an 
effusion of serum, the surface is of a much lighter tint, being 
either of a bright-rose tinge, or occasionally not differing 
widely from the integument covering the unaffected portion 
of the member. Either condition may remain quiescent for a 
long period ; may disappear spontaneously, leaving but slight, 
or marked deformity ; or, as a third possible termination, the 
contents may suppurate and be evacuated spontaneously. 

Where the contents consist of extravasated blood the car- 
tilaginous framework has usually been fractured, and certain 
portions will almost inevitably become necrotic and exfoliate 
with the production of considerable deformity. On the other 
hand, a simple perichondritis, where no fracture has taken 
place, may disappear without seriously changing the contour 
of the ear. 

Among professional wrestlers and boxers, the ear is fre- 
quently subjected to violence not sufficient to produce an 
acute perichondritis, but enough to cause a mild inflammation 
of the perichondrium, so slight as to give rise neither to dis- 
comfort to the patient nor to appreciable deformity immedi- 
ately after the injury. This chronic inflammation finally gives 
to the ear an appearance which is somewhat characteristic, 
known as " prize-fighter's ear," all the delicate outlines of the 
anterior surface of the pinna being obliterated by the deposit 
of new tissue in various localities. Occasionally the deformitv 
reaches such a high degree as to resemble closely the condi- 
tion resulting from a severe acute perichondritis with cartilagi- 
uous necrosis. 

Treatment. — The treatment of an acute perichondritis re- 
sulting from contusion consists, first, in the local application 
of cold, provided the case is seen within twenty-four hours after 
the injury has been inflicted. During this period the effusion 




TREATMENT OF CONTUSED WOUNDS. 185 

of serum will scarcely reach any considerable amount, and 
our efforts should be directed to the purpose of preventing 
the extravasation of fluid. The most convenient way of ap- 
plying- cold is by means of the ice bag, 
shown in Fig. 70. The mastoid region 
should be covered by a pad of cotton 
so as to support the bag against the 
posterior surface of the auricle, while 
the anterior surface may be covered by 
a small flat ice bag. 

When seen at a later period and after 
effusion has taken place efforts should 
be directed toward the relief of the de- 
formity. It is a simple matter to as- 
pirate the effused fluid, and cause' the FlG 7a _J^ al ice bag> 
auricle to resume a perfectly normal ap- 
pearance, but unfortunately the result is often but temporary, 
effusion taking place again very soon. It is scarcely neces- 
sary to say that in aspirating the fluid, strict antiseptic pre- 
cautions as to the instruments and the field of operation 
should be observed. After the operation, it is well to insure 
close contact of the surfaces which have been separated by 
the effusion, by means of a clamp, the simplest device being 
an ordinary wooden spring clothes-pin, the spring being so 
weakened as to avoid undue pressure upon the auricle, while 
the skin is protected by covering the anterior and posterior 
aspect of the auricle with a thin pad of cotton. Such a device 
may be worn during the night, and may prevent, to a certain 
extent, the reappearance of the effusion. The pressure excites 
a slight inflammation, which may cause adhesion of the sep- 
arated surfaces and effectually prevent a reaccumulation of 
fluid. Unfortunately, aspiration is not attended by uniformly 
favorable results, and after it has failed once it is not advis- 
able to repeat the procedure. 

The most radical and satisfactory plan is to evacuate the 
fluid by a free incision so as to expose at the same time the 
interior of the sac sufficiently to permit of the proper treat- 
ment of its walls. When the fluid has escaped it is well to 
curette the walls of the sac by means of a sharp spoon, after 
which the cavity is packed with iodoform gauze, the aim be- 
ing to obliterate the space by granulation. In opening the 
cyst, care should be taken to make the line of incision conform 



1 86 WOUNDS AND INJURIES OF THE AURICLE. 

with one of the natural folds of the auricle, thus avoiding any 
deformity from the cicatrix. With proper care in conducting 
the operation, so as to avoid suppuration, recovery without 
appreciable deformity is the rule. 

When the case is seen at a still later period, and where the 
injury has been so severe as to result in cartilaginous necrosis, 
the only procedure available is that of incision. This should 
be free enough to permit of the removal of all disintegrated 
cartilage, softened areas being scraped with a sharp spoon 
until completely healthy tissue is reached. The subsequent 
treatment is the same as that advocated above. 

We have spoken of the various wounds which may occur 
in this region, and we need mention only those injuries which 
may be inflicted either by the potential cautery, by chemical 
agents, or by intense cold. Aside from the destruction of tis- 
sue which may result from the action of the potential cautery, 
or strong acids or alkalies upon the auricle, the effects pro- 
duced resemble closely those observed after severe contusions, 
the condition being essentially one of perichondritis. The 
wounds caused by the various escharotic agents, either poten- 
tial or chemical, will be treated upon general surgical princi- 
ples. The most common example of traumatism comprised 
under this head is that which follows exposure to intense cold. 
When the ears have been " frozen," if the patient presents im- 
mediately, the parts should be restored to their normal tem- 
perature gradually, by the application first of pounded ice and 
then of cold water, the temperature being increased gradually 
to avoid a sudden disturbance of circulation in the part af- 
fected. The ultimate result of a prolonged exposure to cold, 
may be a perichondritis followed by cartilaginous necrosis and 
the formation of sinuses upon the anterior and posterior sur- 
faces of the part. Such a condition is to be dealt with surgi- 
cally ; the sinuses must be laid open, all necrotic tissue re- 
moved, and the wound be allowed to heal by granulation. If 
care is taken but little deformity need result. 



CHAPTER VII. 

CUTANEOUS DISEASES OF THE AURICLE. 

Intertrigo. — This disease is observed most frequently in 
young children, in whom it is caused by the pernicious habit, 
so common among the laity, of covering the ears and pressing 
them close to the side of the head by means of a tight fitting 
cap or bonnet. Among the poorer classes this head-dress is 
worn for a great portion of the twenty-four hours. This habit 
is persisted in both in summer and winter, the result being that 
the cutaneous surfaces of the posterior aspect of the auricle 
and of the adjacent integument of the head are kept closely 
in contact, and under the influence of the natural heat and 
moisture of the body. The result is a desquamation of the 
superficial epithelium of the integument, leaving the deeper 
layer of the skin exposed to the air. When this has occurred 
over a small area the local process becomes intensified from 
the hypersecretion which takes place from the denuded sur- 
faces, and from the mechanical irritation produced by the child 
in its efforts to relieve the intense itching. When seen by the 
physician the adjacent surfaces of the auricle and of the side 
of the head are reddened and moistened with serum, which 
has transuded freely. There is no thickening of the integu- 
ment over the affected area, a fact which serves to distinguish 
the disease from eczema, which soon follows unless relief is 
obtained. 

Aside from the mechanical causes tending to produce the 
disease, it is probable that the condition is more commonly 
found among poorly nourished children than among those 
who are well cared for. An hereditary predisposition can 
scarcely be said to cause intertrigo, although it is more com- 
mon where there is a history of eczema in preceding genera- 
tions than where such history is wanting, the cutaneous struc- 
tures apparently, being more easily influenced by a slight local 
exciting cause, as mechanical irritation, than would otherwise 

(187) 



188 CUTANEOUS DISEASES OE THE AURICLE. 

be the case. Lack of proper attention to cleanliness is nat- 
urally an important factor as well. 

The treatment consists merely in keeping the denuded sur- 
faces apart and protecting them from traumatism. All head 
gear which would keep these surfaces in contact should be 
discarded, and the affected areas should be separated by a thin 
layer of gauze smeared with vaseline, cold cream, or other 
bland oleaginous medicament. In mild cases merely dusting 
the surfaces with lycopodium powder, finely divided zinc ox- 
ide, zinc oleate, subnitrate of bismuth, or one of the various 
toilet powders in common use, will ordinarily be sufficient to 
correct the trouble. These applications relieve the itching, 
and consequently the child does not interfere with the prog- 
ress of the disease toward spontaneous recovery. 

Eczema. — This disease occurs either as an acute or chronic 
affection. In all cases probably, there is either some heredi- 
tary predisposition, such as a gouty or rheumatic diathesis, or 
some disordered condition of the primse viae, irregular habits 
of life, improper or insufficient food, etc. 

In addition to a predisposing cause some local exciting in- 
fluence can usually be made out. The most frequent among 
these is a discharge from the external auditory meatus. This 
condition, while in the vast majority of cases not leading to an 
eczema of the auricle, causes the disease in those predisposed 
to it on account of the reasons named above. Among chil- 
dren the habit of covering the ears, which results, as already 
mentioned, in an intertrigo, is frequently responsible for the 
appearance of eczema. 

At the beginning of an acute attack there is usually a feel- 
ing of burning or discomfort in some portion of the auricle, 
usually in those regions where the cutaneous surfaces are 
somewhat closely opposed, as in the fossa of the helix, or in 
the fissure intertragica, or at the orifice of the meatus, or just 
behind and below the lobule. In children the region imme- 
diately behind the ear is a favorite location. The feeling 
of discomfort soon changes to one of intense pruritus. To 
relieve this the patient scratches the part vigorously, in- 
creasing rather than diminishing the local hyperassthesia. 
The affected surface becomes reddened, soon loses its super- 
ficial epithelial layer, is moist from the transudation of se- 
rum, or in the later stages may be covered with crusts, the 
removal of which reveals the bright-red color of the inflamed 



ECZEMA— TREATMENT. 1 89 

integument. Instead of appearing in this form, we occasion- 
ally have a group of vesicles marking the affected locality. 
These vesicles, by inoculation from the air, soon become pus- 
tular, rupture, and give rise to thick, dirty yellowish crusts, 
the removal of which is frequently attended by slight haemor- 
rhage. The condition constitutes a true inflammation of the 
skin, with infiltration of its deeper layers. Palpation reveals 
this fact, the integument feeling thick and somewhat stiff over 
the entire affected area, this sensation diminishing gradually 
as the healthy integument is approached. Where a local cause 
is the most prominent factor the affection is unilateral, but 
where a strong constitutional element is present both organs 
are affected as a rule. When the disease begins upon the auri- 
cle the affection frequently spreads to the canal, producing 
symptoms which will be described later. Frequently after 
the disease has persisted for some time the superficial cervical 
lymphatics are enlarged. 

In the chronic form of the disease the entire auricle may 
be involved, or only limited portions of it. The part affected 
is either of a dull pinkish color, the surface being glossy and 
polished, as though the skin were very thin and tightly drawn, 
or in other cases the superficial epithelium is cast off too rap- 
idly, covering the surface here and there with minute whitish 
crusts or scales. From the efforts of the patient to relieve the 
pruritus these scales are picked off, frequently causing a slight 
abrasion of the surface, and increasing the activity of the local 
process. On palpation the skin feels hard, leathery, and thick, 
especially where the patient has subjected it to mechanical irri- 
tation for the relief of the itching. Over the unbroken surface 
the thickened integument has a peculiar smooth, glossy feel. 
De Rossi* has described a case in which the entire cartilagi- 
nous framework of the auricle became necrotic as the result 
of chronic eczema. It seems probable that there must have 
been some underlying cause other than eczema, to produce 
this destruction of tissue. 

Treatment. — Our treatment should be directed to the re- 
moval of the local exciting cause and to the relief of the con- 
stitutional element of which the disease is but a local manifes- 
tation. Thus in the acute form the dietary of the patient will 
frequently need correction, and the elimination of certain arti- 

* Archiv fur Ohrenheilkunde, vol. xxi, p. 193. 



190 CUTANEOUS DISEASES OF THE AURICLE. 

cles of food or the addition of others will be followed by sat- 
isfactory response to local applications. Diathetic conditions 
must be managed according to general rules. Moderately 
large doses of alkalies, either in the form of Rochelle salts, 
bi-carbonate, acetate, or citrate of sodium, frequently bring 
about a favorable termination where local treatment alone 
has been useless. 

Turning to the local measures to be employed, any dis- 
charge from the meatus must receive proper attention, as its 
presence excites the cutaneous infiltration. In the acute form 
our first efforts are to relieve the subjective symptoms. To 
this end cold applications in the form of evaporating lotions 
are of service. The ordinary lead and opium wash is a favor- 
ite remedy in the acute stage, but is disagreeable on account 
of the color which it imparts to the skin, and because of its 
characteristic odor. Such objections do not apply to the fol- 
lowing : 

5, Liquor plumbi subacetat 3 j ; 

Bismuthi subnitrat 3 ss. ; 

Morphinae gr. ij ; 

Glycerini § j ; 

Aquas rosas q. s. ad § viij. 

M. Sig. : Apply locally as a wet dressing. Shake before 
using. 

Instead of cold applications, better results are sometimes 
obtained, especially where the thickening is inconsiderable and 
the discharge from the surface profuse, by employing the local 
remedy in the form of a powder rather than as a solution. 
Here we may use the oxide of zinc, subnitrate of bismuth, 
starch, lycopodium, stearate of zinc, etc. Where the affection 
causes a most intense burning of the skin an oleaginous sub- 
stance is the most desirable vehicle. The following ointment 
may be used : 

5 Bismuth subnitratis 3 ij ; 

Acidi borici 3 j ; 

Morphinae gr. j ; 

Unguenti zinci oxidi 5 ss - J 

Petrolati q. s. ad J j. 

The same emollient effect is obtained by employing the 
stearate of zinc in combination with boracic acid and sub- 
nitrate of bismuth, and the oily vehicle is avoided. 



ECZEMA— TREATMENT. 



I 9 I 



Owing to the frequency with which any condition attended 
with an increased secretion leads to the development of an 
aspergillus within the external auditory meatus, it is advisa- 
ble if the disease continues for any considerable period and in- 
volves the parts about the orifice of the canal, to add salicylic 
acid to any oleaginous preparation which ma}' be employed 
as a local application, for the purpose of preventing the devel- 
opment of such a parasite. In order to act in this manner the 
salicylic acid must be present in the ointment in the propor- 
tion of about one and a half to two and a half per cent, a de- 
gree of concentration which does not act as an irritant to the 
sensitive cutis. Eitelberg * has employed an ointment of cre- 
olin in the strength of about two per cent with success. 
Where crust formation is a prominent feature of the affection, 
as occurs when the acute stage has passed, all aqueous solu- 
tions are contraindicated. The crusts should first be removed 
by softening them with olive oil or vaseline, after which the 
surface may be medicated either with one of the above oint- 
ments or with a proper powder. Salicylic acid in alcohol in 
the strength of twenty to fort) 7 grains to the ounce may 
occasionally be employed, although in my own experience 
alcohol has proved of but little service in eczema of the 
auricle. 

It should be remembered that the exposure of the denuded 
surface to the air is undesirable, and that the affected parts 
should be constantly protected by some non-irritant or slightly 
astringent ointment, such as the oxide of zinc, cold cream, or 
simple vaseline. 

Nitrate of silver in aqueous solution has many advocates 
as a remedy for the disease. It is customary in using this 
remedy, to begin the treatment with a solution of about ten 
grains to the ounce, the strength being increased until the de- 
sired effect is obtained. I have seen excellent results follow 
the application of such a solution, after the thickening has been 
reduced, as the stimulating effect of the astringent lotion has- 
tens the development of a protecting epithelial layer. 

Where the thickening of the integument is marked, a con- 
dition which must exist when the disease has persisted for any 
length of time, it will be impossible to effect a permanent cure 
without relieving the affected area of the serous infiltration. 

* Wien. med. Press., 1888, No. 13. 



I 9 2 CUTANEOUS DISEASES OF THE AURICLE. 

It may be possible, without doing this, to cause a temporary 
improvement, and to succeed in causing the part to become 
covered with a thin layer of superficial epithelium ; as soon as 
the treatment is discontinued, however, the disease will recur 
in an aggravated form, and where there is much induration we 
should direct our attention to this at once. For this purpose 
the area involved may be thoroughly scoured with green soap, 
the alkali which this contains causing a temporary stimulation 
of the surface, through which the tissues are relieved of the 
serous infiltration, by the free exudation of fluid. This process 
may be repeated every second or third day until the integu- 
ment regains its normal texture, after which the use of emol- 
lient and astringent applications will cause a speedy return to 
a normal condition, and effect a permanent cure. A similar 
result may sometimes be obtained by an ointment containing 
chrysarobin, or pyrogallic acid, or oil of cade. The ammoni- 
ated mercurial ointment also serves a similar purpose. My best 
results in this class of cases have been obtained by employing 
the acetum cantharidis, which quickly relieves the engorge- 
ment of the deeper layers of the integument, while at the same 
time the intense pruritus is alleviated. Considerable care is 
to be exercised in applying this remedy, since if it is used in 
too large quantities the surface may be blistered and the pa- 
tient be subjected to considerable discomfort. The acetum 
cantharidis is to be applied to the affected areas by means of 
a cotton mop, the parts being first lightly brushed with the 
solution and the application repeated on the following day if 
no effect has been produced. As a result of the application 
of this remedy a free serous transudation takes place, and soon 
the parts become covered with a normal epithelium, the ex- 
uded serum drying upon the surface in the form of a thin yel- 
lowish crust, which can either be removed with the aid of the 
forceps on the second day, or, if left to itself, will become dis- 
integrated and exfoliate as a thin, scaly desquamation. If the 
action of the cantharides is too vigorous the application of 
some oleaginous preparation for twenty-four hours will re- 
lieve all discomfort. The application of the cantharides may 
be repeated at frequent intervals until the infiltration has en- 
tirely disappeared. 

We should add, in closing, that constitutional medication 
and local applications must go hand in hand in combating 
the affection under consideration. 



PEMPHIGUS— HERPES. I93 

Pemphigus. — This is a somewhat rare cutaneous disease, 
but is occasionally observed. Its characteristic appearance 
differs in no way from pemphigus developing- upon other 
portions of the body. The condition manifests itself in the 
formation of large blebs filled with a clear serous fluid. Al- 
though the favorite site for the development upon the auricle 
is the margin of the helix and the lobule, it is occasionally 
found in other situations. 

From local infection, this serous fluid may become turbid, 
but it is rarely purulent. The bullae rupture spontaneously 
at the end of a few days, and if the walls are not destroyed, 
protect the denuded area which they cover, and are subse- 
quently cast off in the form of scales, their former site being 
marked by a slight redness of the integument. On the other 
hand, if the sac is entirely destroyed an eroded surface is 
left. This seldom persists for any length of time, becoming 
rapidly dry, the integument remaining slightly reddened in 
this situation. No pain attends these local manifestations, and 
the disease is of importance simply on account of the fact that 
the patient is ordinarily afflicted by several successive crops 
of bullae, which are a source of annoyance because of the dis- 
figurement. 

The best results are obtained by puncturing the thin en- 
velope which incloses the fluid, and coating the collapsed sac 
with a layer of flexible collodion to protect the surface be- 
neath. The internal use of arsenic is the best prophylactic 
measure against recurrence. 

Herpes. — This condition is extremely rare, although a 
search through otological literature furnishes us with quite a 
number of instances of the affection. The disease is essen- 
tially the same as herpes zoster, differing from it only in the 
locality of the cutaneous manifestation. Neurotic subjects 
are particularly predisposed to the affection, although it oc- 
casionally attacks those in perfect health. Indiscretions in 
diet, faulty assimilation, and improper and insufficient food 
may be mentioned among the other predisposing causes. As 
an exciting cause, exposure to cold is the most important ; 
while in a case reported by Chatellier,* it was caused by local 
irritation. The particular pathological condition is obscure, 
but probably consists in a neuritis of the trophic nerves which 

* Annales des mal. de l'oreille., 1886, No. 6. 
14 



94 



CUTANEOUS DISEASES OF THE AURICLE. 



supply the parts involved. These are the auricularis magnus 
and the auriculotemporal, the former coming from the cervi- 
cal plexus, the latter from the third branch of the trigeminus. 

The onset of the affection is commonly marked by severe 
constitutional disturbance, such as an acceleration of the pulse, 
an elevation of the temperature, varying in degree from ioo° 
to 102° Fahr., or even 103 Fahr., headache, and a feeling of 
general lassitude. The characteristic subjective evidence is 
the intense neuralgic pain, which may be confined to the ear 
or may spread over the entire side of the face, following the 
general area of distribution of the nerves involved. Since the 
pain may precede the eruption by several days, the exact diag- 
nosis is often difficult. When the eruption appears, we find 
the portion of the auricle involved covered with groups of 
vesicles which rise from a reddish base and are filled with 
clear serum. Occasionally they coalesce and form a bullous 
eruption. The anterior surface of the auricle is generally 
the region attacked, although in a case reported by Green * 
the posterior surface was involved. The manifestation is 
ordinarily unilateral, but VVagenhaliser f observed an instance 
in which it was bilateral. Although usually confined to the 
auricle, the affection may spread to the canal. A few days 
after their appearance the vesicles rupture, their envelope 
becomes dry and is cast off in the form of minute scales, leav- 
ing the integument beneath of a somewhat reddened or brown- 
ish hue. 

In cachectic individuals superficial ulceration may persist 
for a considerable time over the site of the vesicles. The 
constitutional symptoms, which have been so marked before 
the vesicles appear, usually abate when the eruption becomes 
well marked, although this is not an invariable rule, and the 
general symptoms may persist for a long period after the local 
lesion has entirely disappeared. 

Since diathetic conditions are a prominent causative factor, 
the patient seldom escapes with a single attack of the dis- 
ease, a second or third recurrence being the rule. 

Treatment. — Measures directed toward the relief of the 
condition divide themselves into those for the control of the 
constitutional symptoms and those for the relief of the local 



* American Journal of Otology, vol. iii, No 2. 
f Arch, fiir Ohrenheilkunde, vol. xxvii, p. 159. 



HERPES, TREATMENT— SYPHILIS. 195 

manifestations. Our first measure should be a thorough cleans- 
ing of the alimentary canal by a brisk saline purge, the dietary 
of the patient being at the same time restricted so as to em- 
brace only the simplest articles of food. When the febrile 
movement is prominent the ordinary antipyretics, such as 
antifebrin, antipyrin, or phenacetin, should be administered, 
the last-named drug exerting a favorable influence upon the 
neuralgic pain. When the pain is of unusual severity, aconitia 
in doses of one five hundredth of a grain, repeated every 
hour for three or four doses until the constitutional effects of 
the drug are felt, after which the interval should be increased 
to every three or four hours, can be relied upon to give re- 
lief. Before the appearance of the eruption, cold applications 
are grateful. Iced cloths, the aural ice bag, or a cold lead- 
and-opium lotion may be employed for this purpose. The 
vesicles are best treated by dusting them with a bland powder 
to prevent their early rupture, and where they are confluent 
they may be coated with collodion, for the same purpose. 

If the vesicles are infected and the serous fluid becomes 
purulent, their contents should be evacuated by means of 
a small knife, and the exposed area be dusted with iodo- 
form, iodol, dermatol, or touched lightly with a solution of 
nitrate of silver, to hasten the reparative process. An emolli- 
ent ointment containing morphine or opium is occasionally of 
value. It has been suggested, as a rational means of con- 
trolling the disease, that counter-irritation, by means of the 
actual cautery or by vesicants, be employed over the trunk 
of the nerve involved, but little success has attended this 
method of treatment. Regarding the subcutaneous injection 
of morphine over the affected nerve, it should be remembered 
that disfigurement occasionally follows the use of the hypo- 
dermic needle, and it seems that the advantages are not suf- 
ficient to warrant the physician urging this plan of treat- 
ment. 

Syphilis. — Any syphilitic lesion may appear upon the pin- 
na, although a cutaneous manifestation of this constitutional 
disease is of rare occurrence in the region under consideration. 
Zucker* has reported an instance in which the initial lesion 
was situated upon the tragus, the part being of a dark-pur- 
plish color, and swollen to twice the natural size. There was 

* Zeit. fur Ohrenheilkunde, vol. xiii, p. 167. 



196 CUTANEOUS DISEASES OF THE AURICLE. 

concomitant enlargement of the submaxillary and parotid 
glands. 

The erythematous syphiloderm undoubtedly attacks the 
auricle but, since it causes no symptoms to call attention to 
its presence, is usually overlooked. The macular eruption 
is more frequently observed on account of the distinctive 
appearance to which it gives rise. Occasionally it spreads 
into the canal, for a considerable distance. According to 
Taylor,* those parts supported by cartilage are more fre- 
quently attacked. The papular syphilide is of interest chiefly 
on account of the superficial ulcerations to which it occa- 
sionally gives rise. In an instance under my own obser- 
vation such an ulceration had developed at the junction 
of the lobule with the integument, just below the mastoid. 
The erosion was sharply defined, the surface only slightly 
depressed, and but a slight areola was present. The appear- 
ance resembled an intertrigo so closely that an exact diag- 
nosis was made only upon the failure of the erosion to clear 
up under ordinary local treatment, and its prompt disappear- 
ance upon specific medication. 

A specific eruption of a tubercular character is occasion- 
ally observed. The ulcerated areas are covered by large 
crusts, upon the removal of which the outline of the affected 
portion is seen to be sharply defined. Either the anterior or 
the posterior surface of the external ear may be attacked. A 
correct diagnosis is possible by bearing in mind the sharply 
defined outline of the specific ulceration, its reddish color in 
contradistinction from the irregular grayish-white color of 
tubercular or lupoid ulceration, its slightly depressed surface, 
which is comparatively smooth, in contradistinction to the 
nodular appearance observed in the affections just named, and 
the history of an antecedent specific infection. 

The appearance of a gummy tumor in the external ear is 
one of the rarest manifestations of the constitutional poison. 
Baratouxf has reported an instance in which the infiltration 
was multiple. The deposit presents as a hard, smooth tumor, 
of a deep-red color, and in the early stages does not fluctuate 
upon palpation. At a later period the centre of the mass be- 
comes necrotic, the disintegrated tissue finally breaking down 

* Cited by Rupp, Journal of Cutaneous and Genito-Urinary Diseases, Oct., 1891. 
\ Cited by Rupp, loc. cit. 



SYPHILIS, TREATMENT— LUPUS ERYTHEMATOSUS, igy 

to form pus, which is evacuated spontaneously, unless pre- 
vented by the institution of surgical measures. When left to 
itself the local necrosis results in the development of a deep 
ulcer. 

Treatment. — The treatment of specific lesions of the auri- 
cie corresponds to that of similar conditions in other portions 
of the body. If a gummatous deposit is found before disin- 
tegration has begun, an effort should be made to cause its 
absorption, although this at first may seem hopeless. 

Where ulceration has taken place before the patient comes 
under observation, large doses of the iodide of potassium 
should be at once administered, and for a time local treat- 
ment should consist simply in keeping the parts clean, since 
the reparative process which this drug institutes, frequently 
preserves tissues which seem so disintegrated that the surgeon 
would have no hope of saving them. After the internal med- 
ication has been persisted in for a short time, and its antag- 
onistic action on the constitutional infection is observed in 
the ulceration, we should no longer hesitate to remove all 
those portions which are manifestly beyond repair. The sharp 
spoon is to be called into requisition, and all softened tissue 
thoroughly scraped away. The dressing is carried out upon 
general surgical principles. 

Lupus Erythematosus. — This affection usually attacks the 
auricle secondarily, some other portion of the face being the 
starting point. At first it presents as a sharply defined red- 
dened area, slightly elevated above the surface of the skin, 
over which it soon spreads in all directions. The integument 
involved becomes thick, injected, and separated from the nor- 
mal cutis by a rather sharp line of demarcation. The surface 
is frequently traversed by minute veins. Owing to the in- 
terference with the blood supply, the superficial epithelium is 
thrown off more rapidly than under normal conditions, giving 
the surface a glazed appearance. As the disease encroaches 
more and more upon the healthy integument, its starting 
point becomes somewhat depressed and of a lighter color, 
owing to the gradual sclerosis of the infiltrated tissue. The 
disfigurement constitutes the entire inconvenience which the 
affection entails, there being no pain, pruritus, or perversion 
of sensation. Although usually unilateral, I remember one 
instance in which the entire face, including both auricles, was 
involved. 



198 CUTANEOUS DISEASES OF THE AURICLE. 

A mistake in diagnosis is practically impossible, although 
to a certain extent the disease resembles eczema. In the lat- 
ter affection the intense pruritus, the presence of some local 
exciting cause, the brighter color of the affected part, and 
the moist surface, together with the more rapid progress, 
will usually render a differential diagnosis easy. 

Treatment. — Locally we may employ vigorous friction 
with a strong alkaline soap to relieve the infiltration, after 
which an astringent or soothing ointment may be applied. 
Another plan is to employ counter-irritation in the form of 
tincture of iodine. An ointment containing either iodine and 
iodide of potassium or pyrogallic acid in the strength of from 
one to four per cent is also valuable. 

In the severe cases, the galvano-cautery, the curette, or 
even the knife may be employed, although as a rule these 
vigorous measures are not followed by satisfactory results. 

Lupus Vulgaris. — Dermatological literature teaches us 
that this is one of the rarer cutaneous affections, and its loca- 
tion in the external ear is still more unusual. In the early 
stages we find upon some portion of the auricle one or more 
small hard nodules which cause a slight sensation of itching ; 
the efforts of the patient to relieve this abrade the surface of 
the elevation, which soon becomes covered with a brownish 
crust. As the disease advances the infiltrated areas increase 
in size and number. Those which appear subsequently un- 
dergo the same changes already described as characteristic 
of the original deposit. 

The progress of the affection is slow but steady. The ero- 
sion of the surface gradually becomes deeper and constitutes 
a true ulceration, the areas of local necrosis being almost im- 
mediately covered by brownish crusts which do not separate 
spontaneously. When the crusts are removed artificially the 
ulcer appears but slightly depressed, its margins are poorly 
defined, there is no areola, its boundaries merging impercep- 
tibly into the normal integument. Still later there seems to 
be an effort at spontaneous cicatrization, which results in con- 
siderable deformity due to a shrinking of the cicatrix. The 
affection does not cease spontaneously, and will almost surely 
involve the entire auricle unless checked by local measures. 

Treatment. — When first seen, it is our duty to remove the 
involved area as completely as possible, provided the disease 
is in its earliest stage and limited in extent. In many cases 



LUPUS VULGARIS— TREATMENT. 



I 99 



the complete excision of the infiltrated portion of the auricle 
is the simplest and best measure. Another method is to thor- 
oughly curette away the deposit with a sharp spoon, care 
being taken that the healthy tissue immediately surrounding 
the deposit is encroached upon. The curettement should be 
followed by the application of some chemical agent, lactic acid 
being probably the best. This should be used in concentrated 
solution, and should be thoroughly rubbed into the tissues. 
From the fact that the canal, and even the middle ear, may be 
attacked if the progress in the auricle is not checked, the 
surgeon is fully justified in excising the entire auricle if this 
is so infiltrated as to permit of no other means of eradicating 
the disease. 



CHAPTER VIII. 

INFLAMMATORY AFFECTIONS OF THE AURICLE. 

Perichondritis. — We have already described an inflamma- 
tory condition of the cartilaginous framework of the external 
ear following- an injury to the part. Occasionally such a con- 
dition is met with as an idiopathic affection, or is a complica- 
tion of an acute inflammation of the external auditory meatus. 
The particular part of the auricle affected will depend largely 
upon the locality occupied by the inflammatory process in the 

external auditory meatus, the dis- 
ease spreading by contiguity of 
structure, when depending upon 
such a cause. 

The symptoms to which the 
disease gives rise are a feeling of 
heat in the external ear, quicklv 
followed by severe pain. The 
auricle soon begins to increase 
in size, while over the affected 
area the skin is of a bright-red 
hue, due to an increased arterial 
vascularity. As the disease ad- 
vances the part becomes more 
and more swollen, and the nor- 
mal outline of the auricle entire- 
ly disappears. This is due to an 
effusion of fluid between the car- 
tilage and perichondrium, dis- 
secting this last named structure 
from the underlying cartilage. The fluid is at first serous, 
but quickly becomes purulent. The deformity varies con- 
siderably, according to the particular area involved. Where 
the inflammatory condition within the meatus involves the 
anterior wall, the tragus alone is the part usually affected, 

(200) 




Fig. 



71. — Deformity following peri- 
chondritis. 



PERICHONDRITIS— ERYSIPELAS— ABSCESS. 20 1 

while if the circumscribed inflammatory process is situated 
upon the posterior or superior walls of the canal, the peri- 
chondritis is apt to be extensive, and is accompanied by 
marked deformity. If unrelieved by therapeutic measures 
the fluid is evacuated spontaneously. In such an event 
several sinuses appear either upon the anterior or posterior 
surface of the pinna, and close spontaneously only after a 
prolonged period. A high degree of deformity is the usual 
result in those cases which are allowed to progress without 
surgical interference (Fig. 71). 

Treatment. — The treatment of the condition is identical 
with that advocated in considering perichondritis due to 
traumatic causes, with the exception that aspiration of the 
fluid is not admissible, since its purulent character precludes 
the possibility of a favorable result. In the severe cases 
the procedure advocated by Gruening * of " througb-and- 
through " drainage is probably the most advisable plan 
of treatment. This consists in thoroughly opening the ab- 
scess by means of incisions which pass completely through 
the substance of the auricle from the anterior to the pos- 
terior surface, strips of iodoform gauze being subsequently 
passed through the openings thus made. In a case under the 
care of the author the tragus was the part involved, and a 
rapid cure followed free incision, with a thorough curetting 
of the cavity. 

Erysipelas. — This affection occurs as a complication of 
facial erysipelas, and requires no special consideration either 
as regards the clinical course which it runs, or the treatment 
to be instituted for its relief. 

Abscess. — An abscess of the auricle involving its cartilagi- 
nous portion constitutes in reality a perichondritis, a con- 
dition which has already been described in detail. Occasion- 
ally we meet with a localized collection of pus in that portion 
of the auricle consisting of fibrous and fatty tissue — the lobule. 
Most frequently the affection depends upon a local infection, 
either from an earring or following the operation of piercing 
the ears. Evacuation of the abscess by incision is followed 
by complete and rapid recovery. 

Occasionally we find a superficial abscess in other portions 
of the auricle, the cartilaginous framework being uninvolved ; 

* Archives of Otology, vol. xix, p. 22. 



202 INFLAMMATORY AFFECTIONS OF THE AURICLE. 



these constitute really retention cysts, and are caused by the 
blocking up of the orifice of a sebaceous follicle with sub- 
sequent disintegration of the retained secretion. In the early 
stages, when the condition is one of retention only, removal 
of the obstruction is all that is necessary. After decomposi- 
tion has taken place, however, the proper procedure is to in- 
cise the tumor freely, after which the lining membrane is to 
be dissected out or thoroughly curetted, to prevent recur- 
rence. 

Othematoma (Fig. 72). — A transudation of sanguineous 
fluid beneath the perichondrium is frequently met with as the 
result of an injury. Occurring, however, without the history 

of traumatism, the origin of the 
condition has been a matter of no 
little speculation. While hasma- 
toma auris is frequently met with 
among the insane, numerous au- 
thentic reports are found in which 
if the affection has occurred sponta- 
neously, in persons of perfectly 
sound mind. Age seems to exert 
but little causative influence, Weil * 
having reported a case occurring 
at the age of fifteen months. 

The condition is present usu- 
ally upon one side only, although 
in a case reported by Brunnerf 
its occurrence upon one side was 
followed, a year later, by a similar 
condition in the opposite organ. 
From the fact that it has been frequently observed among 
the insane it is possible that some intracranial lesion may be 
responsible for its occurrence. The investigations of Brown- 
Sequard ^ would add weight to this view, since they show 
that section of the restiform bodies in dogs will produce the 
local lesion in question. It is quite probable that in many 
cases an injury which has been entirely forgotten is the real 
cause of the pathological condition. Flesch* believes that 




Fig. 72. — Othematoma. 



* Monatsschrift fur Ohrenheilkunde, 1883, No. 3. 
f Archiv fur Ohrenheilkunde, vol. v, 26. 

\ Canstatter Jahresbericht, 1869, vol. ii, p. 27. 

# Archiv fiir Ohrenheilkunde, vol. xx, p. 291. 



OTHEMATOMA— TREATMENT. 



203 



certain variations in the structure of the auricular cartilages 
predispose to the extravasation of blood, but advances no 
theory as to the cause of the anomalous structure of the car- 
tilage. It can only be said, therefore, that the setiological 
factor in a proportion of the cases is still unsolved. 

The affection consists essentially in an effusion of blood, 
which separates the perichondrium from the cartilage. Oc- 
casionally we find, on examining the walls of the cavity, that 
small plates of cartilage have been forcibly torn from the 
framework of the auricle during the process of extravasation. 
The tumefaction appears, as a rule, somewhat suddenly. It 
may be preceded by a feeling of burning or pruritus, but usu- 
ally there are no prodromal symptoms. The anterior surface 
of the auricle is usually involved to a greater or less extent, 
and the obliteration of the normal outline is correspondingly 
complete. The integument covering the tumor is either 
normal in color or, if the effusion is large in amount, may ap- 
pear pale on account of the pressure. 

After its appearance, the effusion may disappear spon- 
taneously, or it may be evacuated by spontaneous rupture, 
or the contents of the cyst may suppurate. Absorption is so 
uncommon that we should never wait for its occurrence, 
while it is probable that traumatism is responsible for the 
spontaneous evacuation of the fluid in most cases, whether 
this occurs with or without suppuration. 

Treatment. — The treatment varies according to the size 
of the tumor and nature of its contents, whether this consists 
of blood alone or whether purulent infection has already oc- 
curred. 

When there are evidences of pus formation free evacua- 
tion should be at once resorted to, the case being treated as 
one of simple perichondritis. 

Where the tumor is small and of recent occurrence, simple 
pressure by means of a compress held firmly in place by a 
roller bandage should first be tried. This method, combined 
with systematic massage of the auricle, is valuable in many 
instances. In tumors of large size resort may be had to 
aspiration, followed by the compress, bandage, and massage. 
Where the effusion is of such proportions as to cause consid- 
erable tension of the overlying tissues, evacuation by free 
incision is the most advisable procedure, the cavity being 
afterward thoroughly curetted to remove all necrotic tissue 



204 INFLAMMATORY AFFECTIONS OF THE AURICLE. 

and to favor a rapid obliteration of the space by granulation 
and adhesion. After thus thoroughly removing the contents 
of the cyst the wound should be packed firmly with iodoform 
gauze, and subsequently managed according to the rules of 
general surgery. 

It should always be remembered that in the severe cases 
considerable deformity of the auricle may follow, and the 
patient should be warned accordingly. 

Thickening of the Lobule. — This condition consists of a 
hypertrophy both of the connective tissue forming the frame- 
work of the lobule and of the glandular structures of the re- 
gion, as the result of a chronic inflammatory process. The 
most frequent cause of the affection is mechanical irritation, 
occasioned by the wearing of a ring in the ear, the margins 
of the artificial opening through which this is passed instead 
of cicatrizing and becoming covered with normal epithelium 
remaining denuded, and thus afford an avenue for the entrance 
of infectious germs. Some metals are easily acted upon by 
moist air, and are particularly prone to cause such a condi- 
tion, the products of their oxidation destroying the newly 
formed epithelial cells and leading to the result above given. 
When this process has continued for some length of time the 
pendent portion of the auricle becomes elongated, thickened, 
tender to the touch, and in some cases the seat of spontaneous 
pain. The chief annoyance to which it gives rise, however, 
is the deformity. Occasionally the lodgment of more virulent 
bacteria upon this denuded surface produces small abscesses. 

Treatment. — The treatment of the condition is simple, 
and consists first in the removal of the local cause. If the 
deformity has reached a high degree a plastic operation may 
become necessary for the removal of the superabundant tissue. 

Ossification. — Curiously enough, this condition is exceed- 
ingly rare, although several instances have been mentioned in 
otological literature. The causes which may be considered 
to be active in its production seem to be malnutrition, severe 
local inflammation, or some profound disturbance of the cir- 
culation of the part, such as exposure to intense cold. When 
osseous tissue has once been deposited, the recognition of 
the affection is exceedingly simple. The auricle becomes 
stiff, inflexible, and boardlike to the touch. The ossification 
may be limited either to a small area or may involve a con- 
siderable portion of the organ. 



OSSIFICATION— GANGRENE. 



205 



In a case reported by Linsmayer* the bony deposit ex- 
tended into the floor of the canal. The helix, scaphoid fossa, 
and antihelix are the regions most frequently affected, and the 
condition may be present upon one or both sides. Relief is 
demanded both on account of the deformity and also because 
of the pain which any pressure upon the rigid organ causes, 
as when the patient attempts to lie upon the affected side. 

Treatment. — The treatment consists in a removal of the 
abnormal deposit where this is of limited extent. Where a 
large part of the auricle is involved amputation of the entire 
organ is justifiable. 

Gangrene. — Complete necrosis of the tissues making up 
the framework and coverings of the external ear is occasion- 
ally met with in cases which have not been subjected to any 
severe traumatism. A marked general cachectic condition, 
following an acute illness which has lowered the vitality of 
the patient greatly, or such as may be occasioned by some 
prolonged suppurative process accompanied by bony necro- 
sis, frequently acts as a predisposing cause. If we combine 
with such a condition slight but continuous pressure upon 
the auricle, as might occur in a patient confined to bed for a 
long period and lying upon one side for a considerable inter- 
val of time, the pressure might be sufficient to determine the 
process under consideration. 

Treatment. — The treatment is sufficiently indicated by 
the causes operative in producing the affection. Supporting 
and stimulating measures are to be adopted for the removal 
of the predisposing cause, while care is to be taken to prevent 
any pressure upon the auricle, bearing in mind the ease with 
which local nutritive processes are interfered with when the 
general tone of the body is greatly lowered. If the process 
has alread}^ developed we should attempt, by means of warm 
applications, to restore the circulation of the region to its 
normal state, and at the same time to favor spontaneous 
separation of the necrotic tissue if local necrosis has occurred. 
Where the necrosis is but superficial, the application of 
strong chemical caustics may hasten repair, the local irrita- 
tion exciting a reactive inflammation which in itself becomes 
a valuable therapeutic measure, causing the early exfoliation 
of the slough and the development of healthy granulations. 



* Wien. Klin. Woch., 1889, No. 12. 



CHAPTER IX. 



BENIGN TUMORS OF THE AURICLE. 

Fibroma. — A fibroid tumor is one of the most common of 
the benign neoplasms which is met with upon the auricle. 
The lobule is the part usually involved. The negro race is 
especially liable to the affection, and among this people the 
growths frequently attain a large size. Local irritation at- 
tendant upon wearing 
ornaments in the ear is 
the most common ex- 
citing astiological factor. 
Although the lobule is 
the part most frequently 
affected, the concha is 
occasionally the site of 
a growth of this charac- 
ter, and in a case report- 
ed by Habermann * the 
external meatus was par- 
tially occluded by the 
tumor, which sprang 
from the concha. 

Upon physical exam- 
ination the tumor pre- 
sents a hard surface, 
which is usually smooth, 
but occasionally nodu- 
lar. Microscopically the 
mass is made up of dense, white, fibrous connective tissue. 
In a case reported by Anton f (Fig. 73) the growth was a 
soft fibroma and contained many connective-tissue cells in- 
terspersed between the fibres. 




Fig. 73. — Soft fibroma filling the concha. 
(Anton.) 



* Archiv fur Ohrenheilkunde, vol. xviii, p. 76. 
f Ibid., vol. xxviii, p. 285. 
(206) 



FIBROMA— LIPOMA— ATHEROMA. 207 

These growths are of especial interest on account of the 
fact that they frequently recur after removal, the recurrent 
tumors occasionally assuming a malignant type, especially 
after repeated operations of excision have been instituted. 

Treatment. — The operative treatment is simple. The mass 
is to be circumscribed with the knife, the incision extending 
through the entire thickness of the affected part and lying 
completely outside of it, within healthy tissue. After the neo- 
plasm has been extirpated the edges of the wound are to be 
brought together by sutures, and the parts dressed according 
to general surgical rules. Recovery is usually uninterrupted. 

Where the tumor involves the lobule the incision should 
be so located as to effect the removal of redundant tissue and 
enable the parts, upon replacement, to be molded into a form 
symmetrical with that of the lobule of the opposite side. 

In addition to pure fibromata, tumors are occasionally met 
with which are made up of a mixture of fibrous tissue with 
myxomatous, cartilaginous, or other elements. In a case re- 
ported by Haug * the growth was lymphangio-fibroma. 

Lipoma. — A true fatty tumor has, so far as I know, never 
been found upon the auricle itself. They are occasionally met 
with, however, in its immediate vicinity, usually just below 
the lobule. Kipp f has reported a case of fibro-lipoma of the 
concha, the microscope showing the presence of cavernous 
tissue as well. 

Atheroma (Figs. 74 and 75). — A tumor of this character 
results from blocking up of the sebaceous follicles with which 
the integument covering the external ear is supplied. The 
secretion which the glands produce is imprisoned by the ste- 
nosis of the orifices of the ducts, dilates the gland cavity, and 
gives rise to a tumefaction of varying size. Where the gland 
is active, the rapid formation of its product may produce so 
much pressure as to cause spontaneous rupture. On the 
other hand, after attaining a certain size the obstruction in 
the duct may be overcome, allowing a sufficient amount of 
the contents to escape to relieve the tension without restor- 
ing the normal patency of the tube. This process may be 
repeated indefinitely, and the patient presents with the his- 
tory of a recurrent discharge from the growth at varying 

* Archiv fur Ohrenheilkunde, vol. xxxii, p. 161. 

f Transactions of the American Otological Society, vol. iii, part iii. 



208 



BENIGN TUMORS OF THE AURICLE. 




intervals. Again, the pressure may be so severe as to excite 
an inflammation within the sac, with the consequent produc- 
tion of a purulent discharge. 

The lobule is a favorite seat for these 
growths, or the junction of the lobule with 
the skin of the neck. Marian * has re- 
ported a case in which the neoplasm filled 
the concha. Where spontaneous evacua- 
tion has not taken place dissection usually 
reveals a distinct sac. Where the con- 
tents of the cyst have undergone infection 
and rupture has occurred as the result of 
an inflammatory process, the lining mem- 
brane is usually so amalgamated with the 
surrounding tissues 
as to render its rec- 
ognition as a dis- 
tinct structure dif- 
ficult. 

Under the mi- 
. , croscope the con- 

Fig. 74. — Atheroma. r 

tents of such a tu- 
mor is found to be made up of seba- 
ceous material, degenerated epithelial 
cells, with an occasional admixture of 
cholesterin crystals. 

Treatment. — This condition is best 
combated by surgical interference. 
This consists in the removal of the 
growth. An incision is made through 

the overlying integument, and the tu- Fl( v 75-— Sebaceous tumor of 

, „, , the lobule. (Claiborne.) 

mor is shelled out from the envelope 

without rupture of the sac. In this way a possible recur- 
rence is guarded against. Such a procedure, however, is 
frequently impossible, the sac being opened and its contents 
being evacuated in spite of the greatest care. In this event 
the entire sac should be completely dissected out from the 
structures with which it has become amalgamated. It is well 
after making such a dissection to thoroughly curette the cav- 
ity by means of a sharp spoon, in order that every vestige 




* Archiv fur Ohrenheilkunde, vol. xxv, p. 66. 



ATHEROMA— TREATMENT— ANGIOMA. 



209 



of the enveloping membrane may be removed. Where the 
mass is of but small dimensions and spontaneous discharge 
has taken place, a thorough curetting of the sac, followed by 
the application of a strong solution of nitrate of silver, may 
cause complete obliteration of the cavity and prevent a re- 
currence. 

Angioma. — A neoplasm of this character is seldom met 
with in the external ear, and the reported cases have varied 
greatly both in the area involved by the neoplasm and in the 
degree to which the vascular abnormity has developed. In 
a case reported by Chimani * the condition was one of cirsoid 
aneurism which was present upon the left side of the head at 
birth, and subsequently extended until a large portion of the 
auricle was involved, particularly the posterior aspect of the 
organ. The external ear was displaced outward, and was of 
a dark purplish-red color ; a distinct murmur was perceptible 
over the growth. The condition improved somewhat under 
injections of perchloride of iron, although recurrence took 
place at a subsequent period. The mass was completely dis- 
sipated by a repetition of the same treatment. 

Occasionally an exposure to cold, as in Kipp's f case, seems 
to be responsible for the affection, although in many instances 
they are congenital, differing only in degree from the com- 
mon birthmark or port-wine stain. 

Although we do not consider the condition as perilous to 
life, Jungken $ has reported an instance in which haemorrhage 
from the growth terminated fatally. 

Treatment. — We are usually consulted on account of the 
deformity which these growths cause, and the measures for 
their relief must depend upon their size and character, and 
the coincident presence of a similar condition upon some 
other portion of the face. When involving only the integu- 
ment and consisting of a small stain, repeated applications of 
the galvano-cautery usually obliterate the abnormity. Where 
the mass is of large size and the vessels are more fully devel- 
oped, complete excision is the best procedure. This may be 
effected by seizing the base of the mass with a clamp and re- 
moving it in toto, ligating the stump in several portions. In 
other instances the clamp may be dispensed with, and the 

* Archiv fur Ohrenheilkunde, vol. viii. p. 63. 
•[■Transactions of the American Otological Society, July, 1885. 
\ Schwartze, Ohrenheilkunde, p. 77. 
15 



2io BENIGN TUMORS OF THE AURICLE. 

mass dissected out, the vessels being divided between two 
ligatures, thus preventing excessive haemorrhage during the 
operation. The employment of the ligature to cause the 
growth to slough away slowly is scarcely advisable. 

Injections of fluids for the purpose of coagulating the con- 
tents of the tumor are not free from danger, since by the dis- 
lodgment of a clot, embolism of important vessels may fol- 
low, or general sepsis may result. 

The employment of the galvano-cautery knife or loop for 
the excision of such a neoplasm should only be undertaken if 
a clamp is used, and even if the mass were removed in this 
manner most would prefer to ligate the pedicle in several por- 
tions rather than to trust to a closure of the vessels by the 
action of the incandescent blade or wire. 

Where the tumor increases rapidly in size at the site of its 
first appearance and other areas of the integument become 
involved in regions entirely distinct from the original location, 
we have to deal not only with the lesion as it appears upon 
the external ear, but by our measures for the relief of this, we 
should aim to prevent a similar condition from developing 
subsequently in neighboring regions. This can only be ef- 
fected, I think, by shutting off the arterial supply of the entire 
region by the ligation of the trunk from which the various 
vessels spring. After such an operation the dilated vessels 
will in many instances be obliterated, while those remaining 
will be much diminished in size, and any remaining angioma- 
tous masses can be treated upon the rules already laid 
down. 

It should be remembered that the vessels upon one side of 
the face anastomose freely with those upon the opposite side, 
and less radical measures than those given above may not 
be sufficient to obliterate the condition. 

Cystoma (Fig. 76). — It is still a matter of discussion as to 
what particular form of neoplasm this term should be applied. 
Many use it to designate a localized tumefaction upon the 
auricle due to a circumscribed collection of fluid not de- 
pendent upon traumatism. Many again apply to similar con- 
ditions the term haematoma or perichondritis, although there 
may be no evidence of a sanguineous effusion or of an inflam- 
matory process, and although the history may reveal no ade- 
quate cause for the occurrence of either affection. The for- 
mer view seems to me the more tenable and is advocated 



CYSTOMA. 



211 




by Hartmann,* who applies the name of cyst of the auricle to 
tumors of this description. This opinion is supported by the 
appearance of the interior of the sac, upon incision of the 
tumor. There is no evidence of 
any inflammation of the perichon- 
drium ; there are no fibrinous 
clots, nor any other evidence of a 
previous traumatism. The devel- 
opment seems to depend upon an 
effusion of serum simply. Exposed 
cartilage, however, is occasionally 
found within the cyst. 

These tumors make their ap- 
pearance, as a rule, upon the an- 
terior surface of the auricle, which 
they involve more or less com- 
pletely. The overlying integu- 
ment is normal in color and not 
tender to the touch. The tume- 
faction appears quite suddenly, 
and shows little or no tendency to 

increase in size, relief being demanded simply on account of 
the deformity. Harsh manipulation or contusion of the part 
may cause an inflammation of the cartilage, but this condition 
is superadded, and not a part of the original process. 

The cause of the affection is naturally hypothetical. It 
may possibly be due to a degeneration in the cartilaginous 
framework of the auricle, somewhat similar to that which 
causes the spontaneous development of a hsematoma auris. 

Treatment. — The treatment consists in repeated aspira- 
tion of the fluid or of evacuation by incision, after which 
the cavity is obliterated by packing the wound with gauze. 
Fischenisch f has obtained good results by massage in these 
cases. Manipulation in conjunction with aspiration is cer- 
tainly worthy of trial. After evacuation of the contents of the 
cyst in this manner the walls should be kept in contact by 
means of a properly constructed clamp or by a firm bandage. 

Certainly the surest method of treating these cases is by 
incision. This should be made in one of the natural folds so 



Fig. 76. — Cystoma of auricle. 



* Zeitschrift fiir Ohrenheilkunde, vol. xv, p. 156, and vol. xvii, p. 232. 
f Archiv fiir Ohrenheilkunde, vol. xxv, p. 299. 



212 BENIGN TUMORS OF THE AURICLE. 

as to prevent deformity. After the sac has been thoroughly 
cleansed by irrigation, the margins of the incision may be 
sutured, a few strands of horsehair being passed through the 
sac to act as a drain. By this method a slight irregularity 
may remain at the upper and lower extremities of the incision 
at the points of entrance and exit of the horsehair drain. To 
avoid this, the entire wound upon the anterior surface may 
be sutured, and drainage secured by puncturing the cartilage 
so as to make an opening upon the posterior surface of the 
auricle. By securing drainage through this channel, and 
allowing the incision upon the anterior surface to unite by 
first intention, the probability of recurrence is reduced and 
all deformity avoided. 

Papilloma. — Simple papillomata are found upon the auricle 
onlv in the form of warts. Two instances of anomalous devel- 
opments in the epidermal layer have been reported, which 
might properly be classed under this term. These were ob- 
served by Buck,* and consisted of a dense, hornlike pro- 
tuberance springing from the outer and posterior portion of 
the helix. In one of these the excrescence attained a length 
of three fourths of an inch, while the base was nearly as 
broad. Its growth had undoubtedly been favored by harsh 
methods of treatment. The mass was removed, and complete 
recovery followed. 

* Manual of Diseases of the Ear, New York, 1889, pp. 52, 53. 



CHAPTER X. 

MALIGNANT TUMORS OF THE AURICLE AND OF THE MEATUS. 

It is comparatively seldom that the external ear is the 
primary seat of a malignant neoplasm, although the condition 
is occasionally met with. Any portion of the external ear 
may be the site of the primary deposit, from which situation 
the neoplasm may spread in any direction until a large area is 
involved. In some instances the growth originates in the ex- 
ternal auditory meatus, the auricle being attacked subsequent- 
ly, or the reverse may be true, the growth appearing first 
upon the pinna and extending into the auditory meatus. 

Malignant neoplasms of the deeper portions of the ear or 
mastoid process are still more infrequently met with. The 
most common malignant growth which affects the region in 
question is epithelioma, sarcoma being of rare occurrence. 

Epithelioma. — The same causes operative upon other por- 
tions of the body in the production of malignant growths, act 
here to produce the condition. In a number of instances per- 
sistent mechanical irritation has seemed to be the most prom- 
inent causative factor. In these cases a slight abrasion of the 
external ear subsequently becomes the seat of a malignant 
ulceration on account of the persistent efforts of the patient to 
relieve the local discomfort to which it gives rise. Individuals 
under the age of fifty are seldom attacked, although in one 
instance a malignant growth developed at the age of nineteen. 

The progress of these tumors is usually slower than in the 
other regions of the body, several years being required for 
them to reach any considerable size. Secondary enlargement 
of the cervical glands is not ordinarily present, and for this 
reason the prognosis in malignant disease of the auricle is 
relatively better than that of a similar condition in other 
portions of the body. Even where glandular infiltration has 
occurred there seems to have been little tendency to sys- 
temic infection, and removal of the original mass and of the 
affected lymphatics has been, in the majority of cases, effec- 

(213) 



214 MALIGNANT TUMORS OF THE AURICLE AND MEATUS. 

tual in curing the disease. That systemic infection is so 
slight in cancer of the external ear is probably due to the 
fact that the infectious material is absorbed from cartilaginous 
tissue very slowly, and that the local lesion develops to such 
an extent that it demands removal before extensive glandular 
infiltration has taken place. 

The physical characteristics are almost unmistakable. No 
ulceration resembles in appearance that presented by an epi- 
thelioma. Before ulceration has taken place it may be im- 
possible to decide the character of the neoplasm, although 
from the fact that it does not resemble any of the benign 
growths found here, diagnosis by exclusion is simple. 

After the superficial tissues have broken down the eroded 
surface appears reddened, moist, irregular in outline, and some- 
what raised above the healthy integument surrounding it. 
It bleeds easily on touch, and is frequently tender. Interfer- 
ence with the nutritive supply of the cartilage causes this 
to become necrotic, and with the process of exfoliation inflam- 
matory reaction occurs. Such a condition is characterized 
by the presence of exuberant granulations the same as in a 
simple perichondritis, and during this stage an error in diag- 
nosis may occasionally be made. The true character of the 
tumor can be made out by removing a small portion and sub- 
mitting it to a microscopical examination. The removal of a 
small fragment is easily accomplished by means of the cold 
wire snare, and this aid to diagnosis should always be em- 
ployed before a positive opinion is given. On account of the 
occurrence of exuberant granulation tissue, microscopical evi- 
dence of a negative character does not exclude malignant dis- 
ease, although positive evidence settles the question beyond 
a doubt. 

Treatment. — The results of treatment are unusually favor- 
able. If the mass is removed by radical measures there seems 
to be slight tendency to a recurrence. Lymphatic infiltration 
should be dealt with at the same time, and it is only in ad- 
vanced cases that a fairly favorable prognosis is unwarrant- 
able. The treatment should be the same as that of malignant 
neoplasms in any portion of the body, early removal by the 
knife being the only safe procedure. Care should be taken 
that every vestige of the growth is excised, the incision pass- 
ing beyond the limits of infiltration and lying in perfectly 
healthy tissue. The exact plan to follow will vary with the 



EPITHELIOMA— TREATMENT. 



215 



different cases. If the auricle alone is involved, and the in- 
filtration is extensive, it is best to amputate the pinna at once. 
If possible, when this is done care should be taken to pre- 
serve enough of the integument about the orifice of the 
meatus to permit of its being sutured to the skin of the face, 
thus securing a patulous external canal lined with epidermis. 
Where, however, the growth has extended ever so slightly 
into the canal, the auricle and the entire cartilaginous meatus 
should be removed. When this is necessary it is almost hope- 
less to attempt to secure a patent external meatus, although 
the effort should be made. For this purpose a drainage tube, 
either of soft rubber, silver, or aluminium, should be kept con- 
stantly in the canal in order to preserve its lumen. Such a 
device may be worn for a long period, and be removed once 
daily for the purpose of cleansing the passage, being quickly 
replaced to prevent the occlusion of the canal by the granu- 
lation tissue. Even after such a tube has been worn many 
months the attempt frequently fails. It may be possible in 
some instances to employ skin grafting, either by Thiersch's 
method or by twisting a small flap from the adjoining region 
into the orifice of the canal, and thus secure a proper tegumen- 
tary lining. I have tried neither of these methods, since the 
procedure was not suited to the two cases which came under 
my observation. In one instance, where the growth involved 
the posterior wall of the canal, the meatus was completely ob- 
literated in spite of persistent efforts to maintain its patency. 
In a second case a perfectly patent canal was obtained by 
uniting the integument of the anterior wall of the passage 
with the margin of the cutaneous incision through the skin of 
the face, the cutis being dissected up for a considerable dis- 
tance to permit displacement toward the meatus. Coaptation 
of the edges was not attained, and this does not seem to be 
necessary. The sutures may cut through at the end of a few 
hours and still perform a very important function, the parts 
being held in position for a sufficient length of time to become 
so firmly fixed by plastic effusion as not to retract to any ex- 
tent after the sutures have given way. In the instance named, 
a considerable portion of the wound healed by granulation, 
and there was scarcely any deformity, and but slight con- 
traction at the entrance of the meatus. 

In excising a growth of this character involving a large 
portion of the auricle, a little care will enable the operator to 



2i6 MALIGNANT TUMORS OF THE AURICLE AND MEATUS. 

replace the parts in such a manner as to prevent disfigure- 
ment. Where the parotid gland is involved, it is seldom wise 
to attempt extirpation, although in a robust patient it is per- 
missible. As the facial nerve passes through this large glan- 
dular mass, it is well to warn the patient of the possibility of 
facial paralysis following the operation. 

No special suggestions are necessary concerning the 
course to be pursued with the lymphatic enlargements. 
These are dealt with on general surgical principles. The 
employment of the galvano-cautery, the cold snare, chemical 
caustics, etc., for the removal or the destruction of a malig- 
nant neoplasm of the auricle seems to the author scarcely 
justifiable, although many have used the potential cautery 
upon small growths of this character, with eminently satis- 
factory results. 

Sarcoma. — Occasionally a sarcomatous neoplasm origi- 
nates primarily in the external ear, or, on the other hand, 
this organ may be involved by contiguity of structure from a 
similar growth in the cervical region. The growth exhibits 
no preference for any particular region, any part of the exter- 
nal ear being equally liable to involvement. Extension to the 
external auditory meatus has occurred, and the possibility of 
this should always be borne in mind. Such an extension to the 
canal renders extirpation of the growth less easy and the pos- 
sibility of its occurrence constitutes a plea for early operation. 

The tumor varies in appearance according to its situation, 
and differs from an epithelioma in that ulceration of the sur- 
face does not take place until a comparatively late period. 
The mass is less firm than an epitheliomatous tumor, is usu- 
ally more vascular, the surface being frequently traversed by 
tortuous blood vessels. The tumor may grow slowly and 
exist for many years without giving rise to symptoms suffi- 
ciently urgent to demand operative treatment ; on the other 
hand, these tumors sometimes increase rapidly in size and 
demand interference at an early period. 

Treatment. — The successful treatment depends upon the 
complete removal of the growth, and in these cases, owing to 
the increased vascularity of the mass, it may be wise to em- 
ploy the cold or incandescent ecraseur or the galvano-cautery 
knife. If the mass is completely removed at the point of pri- 
mary deposit, recurrence seldom occurs. Systemic infection 
is rare. 



//. DISEASES OF THE EXTERNAL AUDITORY 

ME A TUS. 

Diseases of the external auditory canal may be divided 
into two classes as regards their causation, duration, and 
extent. 

As regards causation, either primary or secondary. 

As regards duration, either acute or chronic. 

As regards extent, either circumscribed or diffuse. 

While inflammatory changes in this region are often sec- 
ondary to some coexisting condition of the tympanum, either 
circumscribed or diffuse inflammation may occur as an idio- 
pathic disease both in the acute and chronic form. 



CHAPTER XI. 

circumscribed external otitis. 

Acute Circumscribed External Otitis. 

Otitis externa circumscripta acuta. Furuncle. 

Etiology. — The occurrence of a circumscribed inflamma- 
tion within the auditory canal is usually due either to mechan- 
ical irritation, the result of scratching the ear with the finger 
or with some blunt or sharp instrument; to inoculation in the 
same manner; to a loss of superficial epithelium as a result 
of some cutaneous disease, the abraded surface forming the 
point of entrance for pathological bacteria ; or, where the tym- 
panum is the seat of a purulent inflammation, the local infec- 
tion may take place through the ducts of the glands with 
which the meatus is supplied. 

It is doubtful, probably, whether all cases are not the 
result of some local infection, but certain constitutional con- 
ditions predispose strongly to the disease under considera- 
tion. The local lesion sometimes appears without any dis- 

(217) 



218 CIRCUMSCRIBED EXTERNAL OTITIS. 

cernible source of local infection — in other words, it occurs 
as an idiopathic disease. Marked impairment of the general 
health, disturbance of the digestive system, anaemia, and dia- 
betes render an individual particularly susceptible to the 
malady. 

Pathology. — From the anatomical structure of the meatus, 
it follows that as the external or fibro-cartilaginous portion 
is freely supplied with glands, this is the part most usually 
attacked. The inferior, posterior, and superior walls are 
more frequently affected than is the anterior. Usually the 
focus of the inflammation is situated near the orifice of the 
meatus, although it may be located in any portion of the 
canal, and occasionally is met with in the osseous part. The 
abscesses occur usually in groups rather than singly, due to 
the fact, probably, that infectious material from the same 
source has inoculated several glands simultaneously. The 
disappearance of one " crop " is apt to be followed by an- 
other, thus prolonging the course of the affection. This is 
especially true where any diathetic condition is present. 

Loewenberg* lays great stress upon the fact that certain 
micro-organisms are found in the pus discharged from these 
small abscesses. Schimmelbusch,f working in the same line, 
likewise attributes the local abscess to the presence of a ba- 
cillus, but has shown that an abrasion of the normal epithe- 
lium is necessary in order that the germ may develop at any 
point. It has already been stated that an asthenic constitu- 
tional condition in many cases predisposes to the formation 
of these abscesses, the power of resistance to any morbid pro- 
cess under these circumstances being much reduced. There 
is considerable evidence to show that a trophic disturbance 
caused by some obscure condition in the nerve trunks which 
supply the meatus may also be the prominent causative 
factor. 

Urbantschitsch f has reported instances where a derange- 
ment of the trophic nerves of one side, due to a local lesion, 
was followed very quickly by the development of a furuncle 
in that portion of the canal of the opposite side, supplied by 
the corresponding nerve. I myself have seen two cases 

* Deutsch. Med. Woch., 1888, No. 28. 

f Arch, fur Ohrenheilk., vol. xxvii, p. 252. 

% Lehrb. der Ohrenheilk., Vienna, 1890, p. 107 ; Arch, fur Ohren., vol. xxxv, p. 5. 



PATHOLOGY— SYMPTOMATOLOGY. 219 

which were undoubtedly of a reflex tropho-neurotic character. 
One occurred in a boy, aged fifteen, who suffered from a 
severe traumatic external otitis, the abscess being located on 
the posterior wall of the canal. Notwithstanding the fact 
that the patient was in excellent general condition, the oppo- 
site canal, which was apparently healthy up to this time, was 
similarly affected about four days after the incision of the 
first abscess. The identity in the location of the abscess 
upon either side and the absence of any other exciting cause, 
seemed to place this second furuncle in the category under 
discussion. In the second case the development of a small, 
circumscribed area of inflammation upon the floor of the 
right meatus was followed within twenty-four hours by an 
exactly similar condition in the same location upon the oppo- 
site side. In this short interval the local process had reached 
maturity, and when the patient was seen the second abscess 
was discharging, although the region had been inspected with 
great care less than twenty-four hours previously, and was, 
at that time, in a perfectly normal condition. 

We must believe, therefore, that the cause may be reflex 
in character even in cases where the general health is unim- 
paired. After infection has taken place, the inflammatory pro- 
cess advances rapidly, the central portion of the affected area 
losing its vitality and being discharged either "in the form of 
pus or sometimes as a distinct mass of necrotic tissue. Ordi- 
narily the inflammation does not extend deeply by contiguity 
of structure, but when very severe the underlying tissues 
may become affected, developing a perichondritis of the canal 
or auricle. This is particularly apt to take place when the 
furuncle is located on the anterior wall, the entire tragus be- 
coming involved. Exceptionally, the affection may lead to a 
diffuse external otitis, which, spreading along the posterior 
wall of the canal, may give rise to periosteitis of the osseous 
portion, and may thus by extension involve the middle ear 
itself. In either event extension to the mastoid cells may 
occur. 

Symptomatology. — The first symptoms with which the dis- 
ease is ushered in is usually a feeling of fullness or discomfort 
in the ear, or sometimes a slight itching sensation, causing the 
patient to press the finger against the tragus. Soon, how- 
ever, he finds that this part is tender upon pressure, and 
a little later spontaneous pain in the ear becomes very well 



220 CIRCUMSCRIBED EXTERNAL OTITIS. 

marked. At this juncture the hearing- becomes considerably 
interfered with, owing to the stenosis of the meatus resulting 
from the tumefaction. For the same reason there is fre- 
quently tinnitus, usually rather high pitched in character, 
which increases as the affection progresses. This may be 
due either to stenosis of the canal or to the congestion of the 
deeper structures from the increased blood supply. The 
pain increases in severity, so that within twenty-four hours 
from the first feelings of discomfort it may be almost un- 
bearable, while the ear continues to be very tender to the 
touch, especially when pressure is exerted in front of the tra- 
gus. From the intimate relation between the cartilage of the 
tragus and the intermaxillary articulation the motions of the 
lower jaw are interfered with, and mastication frequently be- 
comes so painful that the patient can take liquid food only. 
The spontaneous pain is especially severe at night and fre- 
quently may prevent sleep, although during the day the pa- 
tient may be able to follow his vocation. If the abscess is 
located upon the anterior wall of the. canal the parts in front 
of the ear appear swollen and slightly turgescent. If, on the 
contrary, the posterior wall of the canal is affected, one of the 
frequent symptoms noticed is an undue prominence of the 
auricle, the external ear being crowded somewhat forward 
and standing out more prominently from the side of the head 
than does its fellow on the opposite side. When the furuncle 
is in this location, also, the slightest pressure upon any por- 
tion of the pinna causes intense suffering. When the abscess 
is situated upon the posterior wall, a not infrequent symptom, 
and one to Avhich the patient is apt to attach undue gravity, 
is a marked oedema of the integument behind the ear. 

Infiltration of the cervical glands, and also of the preau- 
ricular glands, is of common occurrence, the former giving 
rise to a hard, irregular swelling extending from just below 
the lobule downward along the course of the sterno-mastoid 
muscle to the angle of the jaw, while in the latter case the 
side of the face immediately in front of the ear presents some 
irregular induration due to an inflammation of the lymphatic 
nodules in this region. The parotid gland itself may also par- 
ticipate in this inflammatory process, causing its outline to 
become distinctly defined both to ocular inspection and to 
palpation. This is due to secondary engorgement of the 
gland, and consequently suppurative inflammation of the paro- 



DIAGNOSIS. 221 

tid occasionally complicates a circumscribed external otitis. 
Occasionally we find directly behind the auricle, a rather 
prominent group of small lymphatic glands ; when these are 
present a localized inflammation upon the posterior wall of 
the canal is attended by considerable infiltration of these 
structures, in which case the oedema before spoken of is re- 
placed by an irregular induration which is so poorly defined 
in its limitations, that it may be mistaken for an inflammatory 
condition of the mastoid periosteum. 

Constitutional symptoms are, as a rule, not well marked. 
The attack may run its course in an adult with scarcely any 
elevation of temperature, or the temperature may be slightly 
elevated — reaching perhaps 99 or ioo°. If glandular inflam- 
mation is present as a secondary affection, the temperature is 
more apt to be elevated than when this does not exist. A feel- 
ing of general malaise, headache, loss of appetite, etc., is attrib- 
utable rather to the loss of sleep and the discomfort attendant 
upon the condition within the canal than to any actual systemic 
infection. After these symptoms have persisted for from forty- 
eight hours to three or four days, they disappear quite sud- 
denly, and coincident with their cessation a purulent discharge 
appears in the meatus. This, it need scarcely be stated, is due 
to the spontaneous rupture of the abscess, the discharge of its 
contents causing an abatement of all the distressing manifes- 
tations. 

As stated under Pathology, however, these abscesses ordi- 
narily appear in groups, so that in the course of a few days 
the symptoms already narrated are repeated. If the inflam- 
matory process extends to the tympanum or to the mastoid 
cells, the pain becomes more intense and the constitutional 
symptoms also are more marked. The temperature rises, the 
pain instead of being localized involves the entire temporal 
region, or may manifest itself as a severe general headache. 
The impairment in hearing and the subjective disturbances 
become more marked, and the gravity of the affection is evi- 
denced by the increased prostration from which the patient 
suffers. 

Diagnosis. — It would seem that the diagnosis of such an 
affection would present no difficulties, but this is frequently 
by no means simple. In the early stages the patient is not 
able to localize the pain, but complains simply of a feeling of 
discomfort and heaviness in the head, and may even ignore 



222 



CIRCUMSCRIBED EXTERNAL OTITIS. 



the ear entirely and refer all the painful sensations to the pres- 
ence of carious teeth. An inspection of the ear at this period 
may reveal absolutely nothing. If, however, we supplement 
ocular inspection by carefully testing the sensitiveness of the 
wails of the canal by means of a cotton-tipped probe, usually 
some one point will be found where pressure causes the pa- 
tient to wince slightly. Too much stress can not be laid, how- 
ever, upon the necessity of first inspecting the ear without the 
use of the speculum, the auricle being drawn upward and 
backward, or in a very young child downward and backward, 
and the entrance of the meatus first examined by reflected 
light before the introduction of any instrument. It is well, 
also, to press gently upon the posterior, inferior, superior, and 
anterior walls of the canal with the cotton-tipped probe before 
introducing the speculum, in order to recognize any tender 
point which might escape detection after the insertion of the 
instrument. Very frequently, at an early stage, this tender- 
ness may be the only evidence suggestive of the local lesion. 
If this examination is made before the speculum is inserted, 
a very slight tumefaction may be observed encroaching upon 
the lumen of the canal, from one of its walls. This area may 
not differ in color from the surrounding parts, or it may be 

of a slightly pinkish or red- 
dish hue. This alteration 
in color is seldom notice- 
able, and the insertion of the 
speculum may entirely ob- 
literate the local swelling. 
The deeper parts should be 
tested, after the speculum 
has been introduced, by 
means of the probe in the 
manner already described, 
and the presence of one or 
more tender points be 
looked upon with suspicion. 
If the local process is more 
advanced the areas of tume- 
faction are easily recognized 
(Fig. yj) ; if the inflammatory process is located near the 
orifice of the canal, the introduction of the speculum may be 
painful. As many patients, however, wince slightly upon 




Fig. 77. — Otitis externa acuta circumscripta, 
at the entrance of the canal involving the 
superior and posterior walls. (Natural 
size.) 



DIAGNOSIS. 



223 



the introduction of any instrument into the meatus, this sign 
should be accepted with considerable caution. As has been 
stated, circumscribed inflammation of the canal is usually 
located in the movable portion, and although occasionally 
occurring in the osseous segment, any localized tumefaction 
in this region should be looked upon with great suspicion, 
especially if situated upon the superior posterior wall, since 
in this locality the mastoid antrum is separated from the 
meatus by a comparatively thin plate of bone, and an inflam- 
mation within the mastoid cells often causes an encroachment 
upon the lumen of the canal in this locality. When this is 
the condition otoscopic ex- 
amination gives the impres- 
sion of a canal which rapid- 
ly becomes narrow at the 
fundus, the line of demar- 
cation between the drum 
membrane and the superior 
and posterior walls of the 
meatus being poorly de- 
fined. In some instances 
only a small slitlike open- 
ing is visible at the inner 
extremity of the canal, the 
membrana tympani being 
completely hidden from 
view except over this area 
(Fig. 78). Such a condition 

means, almost invariably, a collection of fluid within the mas- 
toid antrum, and always indicates an affection of the deeper 
structures, although the process may have had its origin in 
the external meatus ; in other words, the affection is no longer 
confined to the meatus, but involves the middle ear. On the 
contrary, in furuncular inflammation the greatest narrowing 
is at the orifice of the meatus, and if the speculum can once 
be carried past this obstruction, which lies comparatively 
near the external opening of the canal, an unobstructed view 
can be obtained of the parts that lie beyond. Where a cir- 
cumscribed external otitis occurs in an ear which is already 
the seat of a purulent inflammation of the tympanum, the 
location of the tumefaction in the superficial meatus will fre- 
quently enable us to distinguish between a simple circum- 




Fig. 78. — Otitis externa acuta of the deep 
portion of the meatus, indicative of in- 
flammation of the mastoid. (Natural 
size.) 



224 CIRCUMSCRIBED EXTERNAL OTITIS. 

scribed external otitis and one due to an inflammation of the 
mastoid process (compare Figs. 77 and 78). 

External manipulation will reveal considerable tenderness 
upon pressure in front of the tragus if the anterior wall is af- 
fected ; indeed, as the entire fibrocartilaginous portion of the 
canal is moved, to a certain extent, by any pressure in this 
region, this test in adults is of great importance in making the 
differential diagnosis between inflammatory affections of the 
meatus as distinguished from those of deeper parts — that is, of 
the middle ear or of the mastoid process. In the same way 
if the auricle be grasped firmly and moved in various direc- 
tions, any inflammation in the canal will be evidenced by the 
pain which this manipulation causes. It is also well to exert 
pressure upon the walls of the canal from below upward and 
from above downward, and from behind forward successively. 
If the cartilaginous meatus is affected it will be scarcely pos- 
sible not to elicit some tenderness, no matter where the ab- 
scess is located. The occurrence of oedema over the mastoid 
process may lead to the erroneous supposition that the osseous 
structures have become involved. This mistake need never 
be made if care is taken to test for the presence of tenderness 
over the mastoid process itself, without communicating any 
motion to the auricle in applying the pressure. To do this 
the fingers of the hand are rested lightly upon the side of the 
head, while the thumb is pressed firmly over the cedematous 
area, taking care that this pressure shall be exerted just be- 
hind the line of insertion of the auricle, and in a direction 
backward and inward rather than forward and inward. In 
this way the movable portion of the canal is in no way dis- 
turbed and the pressure is brought to bear directly upon the 
mastoid process. It will be found that where the inflamma- 
tion is confined to the canal alone no tenderness is elicited by 
this manipulation, although the thumb may sink quite deeply 
into the cedematous tissues and leave its imprint there when 
removed. As soon, however, as the pressure is directed in 
the slightest degree forward, so as to move either the auricle 
or the fibro-cartilaginous canal, the patient gives evidence of 
intense suffering. Although simple in execution this point is 
of great value, especially in differential diagnosis. In the 
same manner a careful examination of the glandular infiltra- 
tion, either behind the ear or below it, will usually enable 
one to recognize its nature in distinction from a mastoid peri- 



PROGNOSIS. 



225 



osteitis, or an extravasation of pus due to the spontaneous 
evacuation of the mastoid abscess beneath the sterno-mastoid 
muscle through the diagastric fossa. In some instances, how- 
ever, it will be necessary to observe the condition for several 
days before an exact opinion can be arrived at. 

A suppurative inflammation of the parotid gland may oc- 
casionally lead to error. This condition, from the local ten- 
derness, the severe pain upon mastication, and the local tu- 
mefaction of the antero-inferior wall of the canal just within 
the orifice of the meatus, may sometimes be mistaken for a 
furuncle ; especially is this the case when we remember that 
we frequently find the parotid enlarged secondarily as the 
result of the circumscribed external otitis located here. Prac- 
tically such an error would be a matter of no significance, 
since the treatment would be the same. Upon evacuation of 
the abscess, either spontaneously or by incision, the quantity 
of pus discharged would readily show whether we had to 
deal with simple localized inflammation of the canal, or with 
a breaking down of the substance of the parotid, in which the 
pus had made its way to the surface in this situation. 

Prognosis. — When uncomplicated, the affection ordinarily 
runs its course in from four to eight days, the symptoms 
being at their height about the third day. Care must be exer- 
cised in expressing an opinion upon this point, as the succes- 
sive infection of other areas may prolong the affection consid- 
erably. The general health of the patient is a fact of great 
importance in considering how rapidly the termination of 
the disease may be expected, reinfection being much more 
apt to take place if the general condition is impaired. Per- 
sonal cleanliness, precise attention in carrying out the local 
measures instituted for the relief of the condition, and the 
avoidance of any unnecessary handling of the part — all aid in 
bringing about a speedy termination. So far as danger to life 
is concerned, this is usually considered almost nil. It should 
be remembered, however, that in exceptional instances exten- 
sion takes place both to the mastoid cells and to the middle 
ear, and that death has resulted from meningitis or sinus 
thrombosis. Occasionally dehiscences exist in the walls of 
the osseous meatus, rendering extension to the intracranial 
structures easy. It should also be remembered that after 
the contents of the abscess have been evacuated, either spon- 
taneously or by incision, a denuded surface remains, through 
16 



226 CIRCUMSCRIBED EXTERNAL OTITIS. 

which infection may easily take place. The author has seen 
one instance of erysipelatous infection in this region, resulting 
in" death. 

Treatment. — If observed early, our first efforts should be 
directed to abort the attack, if possible, and thus prevent pus 
formation. With this end in view, the local abstraction of 
blood by means of the natural leech, or better, perhaps, by the 
wet cup, should be instituted at once. If the area in front of 
the tragus is tender the blood should be abstracted from this 
region. In an adult two ounces of blood may be taken away 
if the wet cup is used ; if the natural leeches are preferred, 
two or three may be applied directly in front of the tragus. 
When the posterior or superior wall is the site of the inflam- 
mation the best results are obtained by abstracting blood from 
the mastoid region. Owing to the free intercommunication 
of blood vessels in this region it is usually wise to take away 
a greater quantity here than when the leeches are applied 
in front of the tragus. With reference to the relative value 
of the wet cup and the natural leech, it should be stated that 
the wet cup is to be decidedly preferred, except perhaps in 
the case of children under six or seven years of age, who may 
object less forcibly to the natural leech than any instrumental 
procedure. If the natural leech is used, the meatus should 
be occluded with cotton to prevent the animal from attach- 
ing itself within the canal, an accident which has occurred in 
several instances. The chief objection to natural leeches is 
that in many cases they are difficult to apply, and the precise 
quantity of blood taken away can not be estimated. The re- 
sulting hsemorrhage frequently continues for a considerable 
time after the leeches have been removed, and may be a source 
of annoyance both to the patient and his friends. Quite a num- 
ber of instances have been reported in which erysipelas has 
followed their application, a fact which certainly constitutes 
a grave objection. The wet cup, on the contrary, affords us 
a means of taking away the exact amount of blood we deem 
desirable ; it can be easily applied, and, if carefully done, its 
use is not attended by any more than trifling momentary pain. 
In very young children restraint will always be necessary 
whichever method is used, while adults almost invariably 
prefer to endure the momentary suffering which the artificial 
leech causes, rather than to subject themselves to the annoy- 
ance which the application of the natural leech entails. The 



TREATMENT— BLOODLETTING. 



227 



instrumental abstraction of blood may be effected by the use 
of a device which consists of a glass tube closed at one end, 
while the margin of the open extremity is ground accurately 
to permit of its exact application to the integument. The 
interior of the tube is fitted with an air-tight piston, the rod 
of which is provided with a thread. The other extremity of 
the tube is provided with a cap through which the piston rod 
passes. Beyond the cap the piston rod is provided with a 
nut which traverses the thread upon the rod ; by turning this 
nut the piston is made to travel the length of the tube. 

If now the piston is lowered as much as possible, and the 
open extremity of the tube — previously smeared with a little 
vaseline — is applied closely to the skin, successive turns of 
the nut will exhaust the air from the tube and cause an in- 
tense congestion of the area which it covers, while the soft 
parts will bulge into the tube as the air above is rarefied, 
and the pressure of the air without will be sufficiently great 
to hold the apparatus in position. This process of dry cup- 
ping may of itself be sufficient in certain instances to relieve 
the symptoms ; if, however, it is decided to abstract a certain 
quantity of blood, the cup should be left in position for a 
few minutes, after which it should be removed and the local 
congested area punctured in several places, either by means 
of a small, sharp knife or by a scarificator, shown in Fig. 79. 




Fig. 79. — Bacon's scarificator. 

In either case the process is not painful, as the turgescence of 
the parts is so great that but little sensitiveness remains. The 
cup should now be quickly reapplied, when a free flow of 
blood follows, and as much may be removed as seems desira- 
ble. The application of this instrument would at first seem 
painful, on account of the local tenderness in the immediate 
vicinity of the ear ; it should be remembered, however, that 
local bloodletting is applicable only to the early stages 
of the disease, at which period this tenderness is not well 
marked. 

In place of the instrument mentioned above, the author 
employs one in which the scarification is performed without 



228 



CIRCUMSCRIBED EXTERNAL OTITIS. 





the removal of the cup, while the ordinary ear syringe is used 
to exhaust the air. Fig. 80 shows the method of operation, 
and renders a detailed description superfluous. The instru- 
ment is so constructed as to be interchangeable with the tip 

of the ear syringe, 
and thus the neces- 
sity of carrying a 
cumbersome appa- 
ratus is avoided. 
: III; ! As before stated, 

local bloodletting is 
of value in aborting 
the affection only 
in the very early 
stages. When the 
pain has lasted for 
thirty six or forty- 
eight hours before 
the patient is seen 
for the first time, 
this procedure will 
almost always be 
useless as a prophy- 
lactic measure, al- 
though it may tem- 
porarily relieve the 
pain ; usually, how- 
ever, it only adds 
to the discomfort 
which the patient 
is already suffering. 
After the abstraction of a certain amount of blood in the 
very early stages, the local application of cold is of undoubt- 
ed benefit, both for the relief of pain and for the purpose of 
aborting the attack. When the focus of inflammation is lo- 
cated upon the posterior wall of the canal, the application 
of cold may be made by means of the Leiter coil, shown in 
Fig. 81, the coil being so molded that it applies itself closely 
to the surface of the mastoid. The aural ice bag shown in 
Fig. 70 may also be employed for the same purpose. When 
the focus of inflammation is situated elsewhere, the coil be- 
hind the ear is of but little value, and, in order to be efficient, 



Fig. 80. — Author's artificial leech, 
adapted to the ordinary hard- 
rubber ear syringe. The piston- 
rod of the syringe is arranged 
with a bayonet catch to hold it in 
position when it is withdrawn, 
thus maintaining the vacuum. 



TREATMENT— COLD— INSTILLATIONS. 



229 



such an apparatus must be so arranged that a continuous 
stream of cold water is made to pass through a tube bent in 
the form of the letter U, and of such dimensions that it may 
be inserted into the auditory meatus. Theoretically, this is 
the ideal method of treatment; 
practically, it is of little value, for 
when the meatus is inflamed it is 
so tender that the presence of such 
an instrument causes considerable 
discomfort, and by its pressure 
aggravates the condition it is in- 
tended to relieve. Where the 
canal is large, however, the meth- 
od may be tried. 

The instillation of fluid prepa- 
rations to relieve the pain seems 
to me to be a measure of practi- 
cally no value whatever. A glance 
over the literature on the subject 
affords sufficient evidence of this, 
I think, on account of the large 
number of remedies which have 
been advocated. Thus we find 

recommended solutions of morphine, atropine, subacetate 
of lead, cocaine, menthol, oil of eucalyptus, dilute carbolic 
acid, veratrine, and, in fact, all the drugs of the pharma- 
copoeia which have a real or imagined analgesic local action. 
It must be remembered that the absorption of any remedy 
from the unbroken skin takes place very slowly and produces, 
therefore, when applied to the cutis, almost no effect aside 
from that due to the evaporation of the liquid, with the con- 
sequent production of a certain amount of cold. The small 
amount of benefit to be derived from such applications is 
more than counterbalanced, in my opinion, by the sodden 
condition of the epidermis, which is produced by the reten- 
tion of the liquid in the canal, making subsequent instru- 
mental manipulations much more difficult, and masking to a 
very great degree the local appearance upon speculum ex- 
amination. 

No remedies should be employed locally unless the epi- 
dermis has already been exfoliated over a considerable sur- 
face, a condition with which we not unfrequently meet as the 




1. — The Leiter coil. 



230 



CIRCUMSCRIBED EXTERNAL OTITIS. 



result of a previous chronic inflammation. When this condi- 
tion is present, any of the before-mentioned drugs, either 
singly or in combination, may be beneficial. They are most 
conveniently used in the form of gelatin bougies, as advocated 
by Gruber* under the name of amygdale aurium. They con- 
sist essentially of small conical suppositories of gelatin, the 
drug being incorporated in their substance; the heat of the 
canal dissolves the gelatin, and the drug is thus brought 
directly into contact with the walls of the canal and even 
distributed over the inflamed surface. Previous to their in- 
sertion the canal should be thoroughly cleansed with a mild 
antiseptic solution, after which the suppository is inserted and 
the orifice of the meatus closed by a small pledget of cotton. 
This method is certainly preferable to the use of oleaginous 
preparations, and may to an extent relieve the pain if the 
superficial epidermis has desquamated. Care should be taken, 
when any of the stronger alkaloids are used in the external 
meatus, to determine positively that no perforation of the 
membrana tympani is present, since when this condition exists 
absorption may rapidly take place, either from the mucous 
membrane of the middle ear or by passage of the drug into 
the pharynx and subsequently into the stomach — an event 
which would be followed by constitutional effects. If mor- 
phine is to be used, it should be in the form of the alkaloid 
itself and not in the form of one of the salts, since the simple 
alkaloid is more readily absorbed endermically than any of 
its combinations. The cocaine ear bath may relieve the local 
pain somewhat, after the exfoliation of the superficial layer 
of the epidermis, and is principally indicated where the sur- 
geon intends to incise the canal, in the course of a few hours, 
as the slow absorption may produce a certain amount of local 
anaesthesia. 

While cocaine is of great value as a local anaesthetic, its 
local analgesic action is somewhat limited, and for this pur- 
pose we may more advantageously employ an alcoholic solu- 
tion of menthol, dilute carbolic acid, creosote, oil of eucalyp- 
tus, thymol, oil of cloves, or some other aromatic oil. Of 
these remedies, menthol is perhaps the most efficacious in 
relieving the pain, which frequently is not confined to the 
ear, but may manifest itself as an intense neuralgia of the 

* Lehrbuch der Ohrenheilkunde, Vienna, 1888, p. 292. 



TREATMENT— HEAT. 



231 



various branches of the fifth nerve. This use of menthol was 
first advised by Cholewa.* 

In addition to the relief of pain, its action as a germi- 
cide makes it particularly valuable, as it affords a means of 
combating the local infective process and of preventing the 
formation of other abscesses. It is best applied by inserting 
into the canal a long, narrow pledget of cotton previously 
saturated with a ten- to twenty-per-cent solution of the drug 
in albolene or olive oil. The relief obtained is often consid- 
erable. The only objection to its use is the fatty vehicle with 
which it is incorporated. As the menthol is antiseptic, this 
is unimportant. It may be avoided by using an alcoholic 
solution of menthol in the manner above described, or a five- 
per-cent solution may be dropped into the canal at intervals. 
If, for any reason, we prefer to use carbolic acid or creosote, 
the preparations should not contain more than ten per cent of 
the drug. Menthol will probably prove of more value than 
any of the other drugs mentioned above. 

When a patient is observed at a stage too late for us to 
hope to abort the attack, the local abstraction of blood and 
the use of cold applications are worse than useless. The 
application of heat, however, is advantageous, as it relieves, 
to a very great degree, the intense suffering. Moist heat, 
however, is objectionable. The pernicious practice, so com- 
mon, of applying a poultice to the ear, or of putting the heart 
of a roast onion into the canal, the outer layers being applied 
to the outside to retain the heat, can not be too strongly con- 
demned. Such procedures favor the development of suc- 
cessive crops of furuncles by causing a maceration of the 
epidermis lining the canal, and aid subsequent local infection. 
While heat, therefore, is one of our most valuable agents, it 
should be employed as dry heat. This may be secured by 
filling an ordinary flat bottle with hot water, wrapping it in 
several layers of flannel, and resting the head upon it. A 
more elegant form of application is the small Japanese pocket 
stove which is sold in the shops, which when once lighted 
affords us a means of applying dry heat locally, the small box 
being wrapped in flannel and either secured to the side of the 
head by means of a few turns of a bandage — its light weight 
rendering this practicable — or, after being enveloped in sev- 

* Therap. Monatsheft, 1889, No. 6. 



232 



CIRCUMSCRIBED EXTERNAL OTITIS. 



eral layers of cloth, it may be placed upon the pillow and the 
patient may rest the ear upon it. The common hot- water 
bag-, found in every household, can be used in this manner, 
but its employment requires that the patient shall be continu- 
ally in the recumbent position, and this is sometimes undesir- 
able. In addition to these measures, if we wish to apply heat 
more directly to the parts, I sometimes direct patients to cut 
off the finger-tips of an old kid glove and fill them with salt, 
the open extremity being closed either with a few stitches or 
by a few turns of linen thread. These small salt bags may be 
warmed upon a common tin plate on a stove, or over a gas 
flame or oil lamp, after which they may be inserted into the 
meatus. The salt retains its heat for a considerable period, 
especially if the external parts are kept warm by resting the 
head upon a hot-water bag or similar device. 

Bearing in mind that the process is essentially one of local 
infection, our efforts should be directed, not only to the relief 
of the local condition, but to the prevention of the same in- 
fective process at other points in the canal. The canal should 
be thoroughly cleansed with a warm antiseptic solution by 
means of the syringe, using either carbolic acid, in the pro- 
portion of one to sixty, or the bichloride of mercury solution, 
about one to eight thousand. After syringing, which must 
be thoroughly but gently done, the ear is to be carefully 
dried with small pledgets of cotton rolled upon the cotton 
holder, the manipulation being conducted under ocular in- 
spection by means of reflected light. The canal should next 
be filled with an alcoholic solution of boric acid of the 
strength of twenty grains to the ounce. As the sensibility of 
the canal varies considerably in different subjects, the instilla- 
tion of alcohol may cause pain, and it is well to test the sensi- 
tiveness of the parts by touching the walls of the canal with a 
pledget of cotton previously moistened in the solution. If 
this causes pain the solution may be diluted with water, 
the quantity of water being rapidly diminished at each suc- 
cessive application as the sensitiveness of the parts becomes 
less. The instillation of this alcoholic solution should be re- 
peated at least four times during the twenty-four hours, and 
it is often advantageous to repeat it still more frequently. 
The syringing of the canal not only removes any discharge, 
together with exfoliated epithelial cells, but often relieves the 
pain to a very marked degree. Although frequent syringing 



TREATMENT— INCISION. 233 

of the canal is not advocated by the majority of writers, it 
has been my custom, especially in dispensary practice, to 
direct the patient to cleanse the ear in this manner several 
times daily, after which the alcoholic solution may be instilled 
in the manner already described. If the case is seen twice 
daily by the surgeon the patient need not use the syringe at 
home, but may instill the boric-acid solution without previous 
cleansing of the canal. It is seldom necessary for the surgeon 
to see the case as frequently as this, however, and equally 
good results are obtained if the canal is syringed by the pa- 
tient twice or three times daily, the alcoholic solution being 
used after each irrigation. The surgeon should, if possible, 
see the patient daily for the first few days. 

While all of these methods possess a certain amount of 
value the measure which stands pre-eminent in the treatment 
of this affection is that of early incision. To this, I think, we 
should always resort if our efforts to abort the attack by local 
bloodletting are not successful, or if the patient is seen at so 
late a stage as to preclude the possibility of it. It is not 
advisable to wait until the formation of pus has taken place, 
or even until local tumefaction is so extensive as to be easily 
recognized by ocular inspection. The process is most fre- 
quently deeply situated at first, and becomes superficial only 
a short time before spontaneous rupture occurs. Testing the 
walls of the canal by means of a cotton-tipped probe in the 
manner already described will enable the surgeon to recog- 
nize the affected area as certainly as if local tumefaction were 
present. The point of greatest tenderness should be incised 
deeply and freely with a sharp, short, strong-, curved bistoury, 
the incision being carried through the perichondrium or peri- 
osteum, as the case may be. It must be of sufficient length to 
relieve all tension. This procedure is excessively painful — in 
fact, I know of no measure employed in surgery which causes 
such exquisite suffering as the early incision of a localized in- 
flammatory area in the canal, but the relief afforded fully jus- 
tifies the surgeon in inflicting this momentary pain. The 
beneficial results obtained depend not only upon the relief of 
tension, but also upon the very free bleeding which follows, 
this latter result being also beneficial in reducing the liability 
to the development of a similar condition in some other part 
of the canal. General anaesthesia is seldom required, as when 
a properly formed instrument is used it is only necessary to 




234 CIRCUMSCRIBED EXTERNAL OTITIS. 

make the initial puncture under ocular inspection, the sur- 
geon being able to control the extent and direction of the 
incision by his tactile sense quite as well as by the sense of 
sight. The pain may be somewhat lessened by the use of 
cocaine ear baths, previously mentioned, or by freezing the 
part with the chloride-of-methyl spray. This process is in 
itself quite painful, and is scarcely of advantage, as the pain 
is but momentary even when no local anaesthetic is used. 

After the focus of inflammation has been incised the 
rules already given concerning cleansing of the parts should 
be carried out, with the exception that any alcoholic solution 
applied to the canal must be considerably reduced in strength, 
as otherwise severe pain would be produced by its instilla- 
tion. The cleansing may be effected either by the ordinary 
ear syringe (Fig. 82), the small soft-rubber-ball syringe, or, if 
considerable pain persists, a continuous irrigation of the canal 

may be employed. This 
may be carried out by 
using the ordinary foun- 

FiG." 82.-Hard-rubber ear syringe. tain Syringe. ^ A warm 

antiseptic solution, either 
of bichloride of mercury, one to eight thousand, or of boric 
acid, in the proportion of twenty grains to the ounce, may be 
allowed to flow over the parts continuously for a period of 
ten to twenty minutes. If this is done immediately after inci- 
sion, the attendant pain quickly disappears, while the warmth 
of the application favors free haemorrhage from the wound. 
This local depletion both relieves the pain and renders the 
reparative process more rapid. After free incision the relief 
is usually immediate, and in the course of twenty-four hours 
the parts assume more nearly their normal contour. The 
discharge, however, continues for a few days, during which 
time the infection of adjacent areas is very liable to take place 
unless attention is paid to the systematic cleansing of the 
parts, as above advised. Ordinarily the abscess cavity be- 
comes completely obliterated and the canal wall resumes a 
perfectly smooth and normal outline ; exceptionally, where 
the process has been very deep seated and a considerable area 
has been involved, exuberant granulations spring up about 
the margins of the opening. If very large, these may be re- 
moved by means of the cold snare or sharp curette. Usually, 
however, they are so small as to require simple cauterization 



TREATMENT— INTERNAL MEDICATION. 



235 



by a chemical agent. We may employ for this purpose either 
chromic acid or nitrate of silver, the former to be applied in 
substance, a minute bit of the acid being fused upon the tip 
of a metal probe and applied lightly to the efflorescent tissue, 
after this has been previously dried by a pledget of cotton ; 
any excess of acid must be immediately wiped away by means 
of a cotton-tipped probe, as otherwise the agent quickly 
spreads over the walls of the canal, and severe diffuse inflam- 
mation may result. The nitrate of silver may be used in the 
same manner, or may be applied as an aqueous solution of 
from two hundred and forty to four hundred and eighty 
grains to the ounce. I prefer the chromic acid, as in my 
hands, at least, it has never caused any reaction, while oc- 
casionally the silver preparations excite a severe secondary 
inflammation of the walls of the canal. If the destructive 
process has involved not only the integument, but also the 
underlying cartilaginous or bony structures, rather extensive 
necrosis may take place, retarding the healing process to a 
marked degree. In such an event it is well thoroughly to 
curette the cavity, removing all diseased tissue by means of 
the sharp spoon, after which rapid healing ensues. 

In addition to the local measures here advocated, the con- 
dition of the general health should always be borne in mind 
as furnishing a prominent predisposing cause of local disease. 
Especial attention should be paid to the gastro-intestinal canal ; 
constipation, if present, should be relieved, or disorders of the 
digestion corrected by the administration of alkalies or acids, 
as seem indicated. One of the most common causes under- 
lying this affection is simple anaemia. This is best combated 
by the use of some of the ferruginous preparations. Prob- 
ably no specific exists upon which we can depend to pro- 
duce any marked effect upon the progress of the local in- 
flammation. Sulphide of calcium, so much used in general 
furunculosis, has been frequently advocated, and for a con- 
siderable period I administered it regularly in every case, but 
was unable to perceive any beneficial results from its action. 
If its use seems indicated in any instance, it is best given in 
the form of a pill containing one sixth of a grain of the drug. 
One pill is to be taken every hour for six doses, after which 
the interval may be reduced to every two hours. After this 
medication has been - continued for twenty-four or thirty-six 
hours the doses may be repeated less frequently, say at inter- 



236 CIRCUMSCRIBED EXTERNAL OTITIS. 

vals of every four or six hours. It will generally be found, 
however, to exert very little action upon the disease. The 
internal administration of drugs intended to relieve the in- 
tense suffering of the patient is always advisable in the very 
early stages. There can be no question that the relief of pain 
for a period of six or eight hours, when the process is in its 
incipiency, does exert a certain permanent beneficial action, 
the tendency being to increase the resisting power of the pa- 
tient. By relieving the pain or rendering it more bearable, 
our efforts toward aborting the attack will be more successful. 
It is to be borne in mind also that the pain will continue for 
only a comparatively short period of time ; hence, the admin- 
istration of opiates is not open to the objection that the pa- 
tient is liable to acquire the opium habit. In the later stages 
of the affection analgesics are contraindicated, as they may 
mask mastoid involvement. 

Chronic Circumscribed External Otitis. 

But few words need be said in consideration of a circum- 
scribed local inflammation of long duration. It is usually 
symptomatic of some affection of the deeper-seated struc- 
tures, either cartilaginous or bony. In the former instance 
it results from a very severe form of the disease just described, 
while in the latter case it is usually indicative of some patho- 
logical process within the mastoid cells, and is situated in the 
bony canal. The condition which clinically may be considered 
as belonging to this group, although from a pathological 
point of view it should be placed elsewhere, is that met with 
when suppuration takes place in the sebaceous cyst located 
in the meatus. These neoplasms usually occur on the an- 
terior or inferior wails of the canal, near the orifice, and either 
discharge spontaneously, or, if their contents have been evacu- 
ated by surgical means, persist for a long period, the lining 
membrane being of such a nature that adhesive inflammation 
with 'resultant obliteration of the sac is impossible. The 
cavity refills slowly after each evacuation of its contents, and 
the symptoms of obstruction of the meatus due to the pres- 
ence of the tumor, together with intermittent discharge at 
somewhat irregular intervals, are repeated for an indefinite 
period. Under these circumstances simple incision does no 
good, and will afford but temporary relief. The lining mem- 
brane of the sac must either be dissected out entire, or, if this 



CHRONIC CIRCUMSCRIBED EXTERNAL OTITIS. 237 

is impossible on account of the location of the tumor, it must 
be completely destroyed by the curette, after which recovery 
is prompt. 

We shall consider circumscribed inflammation of the bony 
meatus dependent upon mastoid inflammation in the section 
devoted to mastoid disease. 



CHAPTER XII. 

DIFFUSE EXTERNAL OTITIS. 

This affection may occur in either acute or chronic form, 
and, as its name implies, constitutes an inflammation of the ex- 
ternal auditory meatus, in which the local condition, instead of 
being confined to a small area, involves either the entire canal 
or a very large portion of it, the line of demarcation between 
the normal and affected areas not being clearly marked, but 
merging gradually into each other. Since the acute form of 
the disease is frequently dependent for its cause upon a pre- 
viously existing chronic inflammatory process, we will con- 
sider,, first, the chronic, and afterward the acute affection. 

Chronic Diffuse External Otitis. 

This general term applies to the superficial extent of the 
lesion rather than to its severity, and comprises every degree 
of chronic inflammatory condition of a diffuse character, from 
those cases in which only the superficial layer of the epider- 
mis is involved to instances where not only the cutaneous 
lining is affected through its entire depth, but the cartilagi- 
nous and bony framework as well. 

iEtiology. — This disease is less dependent upon constitu- 
tional conditions than is the circumscribed form of inflam- 
mation. Traumatism plays a very prominent part in its pro- 
duction. The impression so common among many that the 
external auditory meatus must be subjected to thorough 
cleansing by means of the corner of the towel wound up so 
as to permit its entrance into the lumen of the canal, or by the 
introduction of various ear sponges, ear spoons, etc., furnishes 
one of the most fruitful sources of mild but persistent inflam- 
matory conditions of diffuse character. Wounds of the canal 
walls, either inflicted by mechanical violence or resulting from 
the bites of insects which find their way into the meatus, are 
also among the most frequent causes of the disease. The ap- 

(238) 



ETIOLOGY— PATHOLOGY. 239 

plication of oleaginous substances to the walls of the canal, 
for the relief of pain in the ear, or sometimes for toothache, 
is practiced not uncommonly among the laity, and furnishes a 
source of irritation to the lining of the canal. Foreign bodies, 
introduced by mistake or design, by their presence alone fre- 
quently cause a condition of diffuse inflammation. The most 
common cause of the condition is some affection of the mid- 
dle ear attended by a purulent discharge. When the walls of 
the canal are continually bathed with such a secretion, they 
soon lose the superficial layer of epithelium through the com- 
bined action of warmth and moisture. Thus a denuded sur- 
face is left, through which infection may take place. This is 
more commonly met with among that class of individuals who 
pay little attention to habits of cleanliness, and hence make no 
effort to keep the passage free from secretion by frequent irri- 
gation. Among the more uncommon causes is the develop- 
ment of vegetable parasites within the canal. These minute 
organisms attach themselves firmly to the walls of the mea- 
tus, and grow for an indefinite period. As their growth con- 
tinues they become firmly imbedded in the deeper layers of 
the integument, and their removal results in the loss of the su- 
perficial epithelium and an exposure of the underlying cells. 
It is probable that the condition never engrafts itself upon a 
perfectly healthy integument — that is, one in which the horny 
layer of the skin is unbroken throughout the entire extent 
of the canal. If, however, the integument at any place is 
abraded, the moist surface forms an excellent soil for the de- 
velopment of a parasite. Having once taken root, the fungus 
may increase indefinitely by subsequent growth. The con- 
tinued presence of fungi produces an effect similar to that of 
a foreign body — that is, it causes an inflammation of the lining 
of the canal. 

Constitutional causes, we have said, are not important fac- 
tors in the production of this disease ; we make one excep- 
tion, however, in the case of eczema of the canal, which, like 
eczema in other parts of the body, is an evidence of some dia- 
thetic condition. 

Pathology. — An affection dependent upon such a variety 
of causes must necessarily present physical characteristics 
differing greatly. Under the milder types we would include 
those cases of augmented glandular activity resulting in an 
increase in amount of the secretion from the sebaceous follicles 



2 4 DIFFUSE EXTERNAL OTITIS. 

with which the skin is supplied. When the inflammation in- 
volves the inter-glandular tissue, as in eczema of the canal, 
there is a certain amount of infiltration of the deeper layers of 
the cutis, causing the superficial epithelium to be cast off more 
rapidly than under normal conditions. According to the de- 
gree of the infiltration of the integument, a greater or less 
amount of serum exudes, which, washing away the desqua- 
mated cells when the transudation is profuse, leaves a red, 
smooth, glistening surface ; or when less fluid is poured out it 
dries upon the walls of the meatus, forming with the desqua- 
mated epithelial cells yellowish crusts, which adhere to the 
canal walls and partially or completely occlude the passage. 
If the process is allowed to progress, actual hypertrophic 
changes take place in the basement membrane and the meatus 
is gradually converted into a tube of very small calibre, the 
opposing walls lying nearly in contact. An inflammation of 
the external canal occurring in the bony portion, where the 
cutaneous lining is very thin, and where it constitutes the peri- 
osteum, may extend to the osseous tissues and produce the 
symptoms which characterize an inflammation of the mastoid 
process, or, where the Rivinian segment is imperfectly closed, 
it may pass by continuity of structure into the tympanum and 
excite an inflammation within this cavity. 

When the inflammation of the canal is due to the presence 
of a foreign body, or follows a wound of the canal, a circum- 
scribed acute inflammation, or the development within the 
meatus of a vegetable parasite, the changes which take place 
vary in intensity, but are of the same character as those above 
described. The superficial epithelium is thrown off rapidlv, 
the deeper layers of the cutis are infiltrated with round cells 
and become thickened, and tissue hypertrophy finally results. 
In the more severe cases tissue necrosis may take place or by 
extension the underlying bone may become involved. 

In some cases we find the activity of the inflammatory 
process directed especially toward a rapid proliferation of the 
superficial epithelial layer of the integument. The flat pave- 
ment cells are thrown off rapidly, and, aggregating in the mea- 
tus, form a compact mass, which completely fills the deeper 
portion of the canal. From the increase in the blood supply 
incident upon inflammation a small amount of serum is tran- 
suded ; the fluid moistens the compact epithelial mass and 
causes it to increase in volume. In this way great pressure 



PATHOLOGY. 



241 



is exerted upon the surrounding bony walls, which may be 
absorbed or become necrotic, or the pressure may be so grad- 
ual as to interfere but little with the nutrition of the parts, 
and result in a dilatation of the deeper portion of the meatus 
by crowding backward that part of the wall which separates 
the canal from the mastoid cells, so as to obliterate the pneu- 
matic spaces of this portion of the temporal bone. 

In the above consideration we have followed the extension 
of the process from the canal inward toward the deeper por- 
tions of the conducting channel. But a diffuse external otitis 
may be of a consecutive nature; that is, the deeper parts may 
be involved first, and by extension produce an inflammation 
of the walls of the meatus. This is particularly true where 
the deep osseous canal is the site affected. The upper and pos- 
terior portions of the canal at this point form the inferior or 
anterior walls of the mastoid process ; hence, an inflammation 
involving the mastoid antrum and the smaller pneumatic 
spaces frequently produces an inflammation of the canal in 
this region diffuse in character, the process being as much a 
mastoid periostitis as if the outer wall of the mastoid, lying 
immediately behind the ear, 
were the part affected. 

While it lies beyond the 
province of this work to give 
any detailed account of the 
microscopic appearances of 
the various forms of vegeta- 
ble parasites found in the 
meatus, certain characteris- 
tics which are common to 
all of these should be under- 
stood, in order that a diag- 
nosis may be made between 
the purely epithelial or des- 
quamative type of inflamma- 
tion and that form dependent 
upon the presence of fungi. 
These fungi present under 
the microscope long fibres or hyphge of a double contour, 
either completely transparent or slightly granular. These 
fibres divide into branches dichotomously (Fig. 83), which 
terminate in a globular head or fruit-sac (sporangium) (Fig. 84) 
17 




Fig. 83. — I >evelopment of a fungus. G, G, 
Sporangia ; H, Hyphae. (Gruber.) 



242 



DIFFUSE EXTERNAL OTITIS. 



filled with minute spherical spores. Examination of the fruit- 
sac at a certain stage of development will show thin filaments 
radiating- from a central stalk toward the periphery through 
the mass of minute spores. These fresh filaments in turn 





Fig. 84. — Microscopical characteristics of otomycosis. 
G, G, Sporangia ; H y Hyphae. (Gruber.) 



develop sporangia, and the process repeats itself indefinitely. 
The recognition, then, of the mycelial filaments or of the 
fruit-heads containing the spores establishes the diagnosis of 
parasitic inflammation. 

Symptomatology. — The symptoms differ in severity in ac- 
cordance with the degree of intensity of the local process. In 
mild cases a sense of constant irritation or itching in the canal 
is the most prominent symptom, the patient continually at- 
tempting to relieve this by the insertion of the tip of the little 
finger as far into the meatus as possible ; this, naturally, only 
tends to aggravate the condition it is intended to relieve. 
When, either from increased glandular activity, as in sebor- 
rhcea, or from actual inflammation, as in eczema or otomycosis, 
the canal becomes to an extent occluded, either by the scale- 
like sebaceous crusts, or by aggregations of epithelium re- 
sulting from eczema, or by masses of vegetable fungi, certain 
symptoms dependent upon this occlusion manifest themselves. 
These may consist in an impairment of the hearing, varying 
in degree according to the extent of obstruction, or there may 
be tinnitus caused by the congestion which the presence of the 



SYMPTOMATOLOGY. 243 

foreign substance induces, or certain reflex symptoms may 
manifest themselves, such as severe pain spreading over the 
distribution of the fifth nerve, headache, either general or 
local, and, rarely, disturbances of a graver nature, dispropor- 
tionate in severity to the local condition. Thus, instances of 
epileptiform attacks have been traced to inflammatory condi- 
tions within the canal, while symptoms referable to the oppo- 
site ear may also be produced by a chronic inflammation of 
the external auditory meatus of one side. A symptom fre- 
quently complained of is that of autophony, the patient's own 
voice seeming to come from the affected side. This occurs 
only when the lumen of the canal is considerably narrowed. 

Cough is a not infrequent symptom of the affection, and 
may, in fact, be the first to attract the attention of the patient 
and cause him to seek advice. In all cases of cough, even al- 
though apparently explainable upon other causes, it is always 
well to examine the external auditory meatus, as an accumu- 
lation of any foreign material, resulting either from desquama- 
tion of the epithelial lining of the canal or from the aggrega- 
tion of a mass of aspergillus, may cause a reflex cough. As 
the affection increases in severity a discharge may make its 
appearance at the orifice of the meatus. This discharge is 
ordinarily scanty, and, in fact, may be so small in amount as to 
appear in the form of crusts about the margin of the meatus, 
the fluid elements having been evaporated. When more pro- 
fuse the discharge is watery in character, but is never large 
in amount. In the milder cases, due to an inflammation of the 
glandular structures alone, the discharge appears in the form 
of minute scales, which are oily to the touch, on account of the 
fatty matters which they contain. Occasionally, in cases of 
very long duration, the inflammation, instead of producing a 
fluid discharge, causes a proliferation of the epithelial lining 
of the meatus. The superficial epithelial cells are rapidly cast 
off, and, aggregating into masses, remain in the canal for a long 
period. These masses of desquamated epithelium absorb the 
watery secretion which the thickened cutaneous lining of the 
canal exudes, and as the process continues' increase steadily in 
size. From the fact of their slow increase in volume these 
epithelial plugs exert a great amount of pressure upon the 
walls of the canal, leading, in some cases, to a dilatation of the 
bony canal, either by causing an absorption of the osseous tis- 
sue or by crowding the thin bony wall upward and outward 



244 



DIFFUSE EXTERNAL OTITIS. 



toward the mastoid cells, which become correspondingly di- 
minished in size. At the same time the osseous tissue under- 
goes certain structural changes as the result of this mechanical 
irritation, so that, instead of presentingthe ordinary cancellous 
appearance, it becomes converted into a hard, ivory-like sub- 
stance of uniform density. This change may extend through- 
out the entire mastoid, all the air spaces being obliterated with 
the exception of the antrum, or, if the pressure is still greater, 
the bony walls of the canal may be absorbed entirely, and the 
upper part of the tympanic cavity and the mastoid cells may 
thus be continuous with the external auditory meatus. 

Glandular enlargement is not uncommon as the result of 
chronic inflammation of the external meatus, and when the 
glands just below the lobule are affected a mistake in diagno- 
sis is possible, the case presenting many of the characteristics 
of a perforation through the tip of the mastoid process. 

We have spoken of dilatation of the bony canal as the re- 
sult of a desquamative inflammation with the consequent ab- 
sorption or displacement of the bony walls. The opposite 
effect may be produced, however, if, instead of causing a des- 
quamation of the superficial epithelium, the deeper layers of 
the integument are the seat of inflammation ; in these cases 
the lumen of the canal may become very narrow — in fact, it 
may be so diminished in size as to admit only the smallest 
probe. This diminution in calibre is due to an actual hyper- 
trophic osteitis rather than to any thickening in the soft parts. 
This change frequently takes place in the cases of diffuse ex- 
ternal otitis which accompany a chronic suppurative process 
within the middle ear. Instead of narrowing the calibre of 
the canal uniformly, certain limited areas within the canal 
may be affected, producing what is known as an exostosis or 
a circumscribed bony growth, which projects to a greater 
or less extent into the passage. These growths are most fre- 
quently situated near the drum membrane, and, according to 
their size, interfere with the function of audition. 

Diagnosis. — The diagnosis of chronic diffuse external otitis 
will be determined both by external manipulation and by ex- 
amination by means of the speculum. We have to distinguish 
by palpation between an affection confined to the canal and 
one involving the mastoid process, as the superior and a por- 
tion of the posterior walls of the meatus form the anterior and 
inferior wall of the mastoid process. It would seem that this 



DIAGNOSIS. 



245 



differentiation is rather superfluous, but the author intends 
here to separate those cases in which the affection of the canal 
is the prominent feature, the mastoid being involved to so 
slight an extent as to give rise to no symptoms and to require 
the employment of no special measures, from those cases in 
which the affection of the canal is merely symptomatic of a 
deep-seated inflammation within the mastoid, in which treat- 
ment must be directed to the mastoid inflammation as the pri- 
mary disease. When the affection is confined to the canal, 
pressure behind the ear, directed backward and inward, will 
fail to elicit tenderness ; if the pressure is exerted in such a 
way as to move the fibro-cartilaginous meatus, very marked 
tenderness will be elicited. In the same way pressure from 
below, above, or in front of the canal will cause more pain 
than if made directly over the mastoid process. The appear- 
ance presented upon inspection by reflected light will vary 
according to the cause and character of the affection, as well 
as with its intensity. In the milder cases, under which we in- 
clude seborrhcea, eczema, and a chronic otitis externa diffusa 
caused by an aspergillus, inspection will show that the walls 
of the canal are covered either partially or completely with 
some foreign substance. In seborrhcea this will be confined 
almost entirely to the cartilaginous meatus, and the deposit 
will appear to be made up of small, thin, yellowish crusts 
which are easily detached and upon compression between 
the finger and thumb have an oily feel. The surface from 
which these small scales are detached is somewhat reddened, 
but not moist. In eczema the crusts are larger, adhere more 
closely to the walls of the meatus, and are evidently made up 
of desquamated cells which have been moistened with serum 
and have become agglutinated into a mass. This collection 
of cast-off cells has subsequently dried into thick, irregular, 
yellowish-brown crusts. Here the affection extends from just 
within the orifice of the meatus to the drum membrane itself ; 
the crusts are detached with some difficulty, their former lo- 
cation presenting as a red, moist area, which, upon being dried 
with a cotton pledget, quickly becomes coated with a thin 
serous transudate. Inspection and tactile manipulation by 
means of the probe demonstrate an evident thickening of the 
deeper layers of the cutis of the canal. 

In the milder forms of aspergillus the canal walls are cov- 
ered, sometimes throughout their entire extent, at other times 



246 



DIFFUSE EXTERNAL OTITIS. 




only here and there, by a whitish or yellowish-white deposit, 
which seems to be closely adherent to the underlying struc- 
tures (Fig. 85). The entire lumen of the canal may appear 
somewhat narrow. Upon using the cotton holder to wipe 
out the meatus, in order that inspection may be more exact, 
the parts may be found to be moist, the instrument removing 
from the walls of the canal, in addition to the moisture which 
it has absorbed, thin, moist flakes or scales, usually of a whit- 
ish color, the surface from 
which they were removed 
appearing denuded. Upon 
attempting thoroughly to 
clear the canal it will often 
be found possible to de- 
tach relatively large thin 
sheets of this deposit, of a 
white or a dirty yellowish- 
brown color, having the 
consistency of moistened 
paper. In this way a com- 
plete cast of the canal from 
the very orifice of the mea- 
tus may be obtained. If the 
process has spread to the 
drum membrane the cast 
will form a blind sac, the 
closed extremity bearing the imprint of the various landmarks 
of the membrana tympani. This deposit is due to the growth 
of low vegetable organisms upon the walls of the meatus. The 
special species of plant life can only be determined by micro- 
scopic investigation ; the varieties met with are extremely 
numerous, but as the treatment of the different forms does 
not vary essentially it is unimportant to discuss the condition 
at length in a treatise devoted particularly to clinical otology. 
Certain macroscopic features, however, enable us to make a 
reasonably accurate diagnosis as to the particular variety of 
plant present in a given case. A white deposit usually con- 
sists of the aspergillus glaucus. Another variety is the asper- 
gillus flavus, the microscopic features of which are shown in 
Fig. 86, while more rarely we find the walls of the canal and 
the surfaces of the membrane covered with irregular black 
spots, a little smaller than the head of a pin, which are the 



Fig. 85. — Otomycosis. The canal is lined 
with a thin deposit which covers the 
walls and the surface of the membrana 
tympani. The punctate areas on the 
membrana are caused by the increased 
growth of the fungus in these situations. 
(Natural size.) 



DIAGNOSIS. 



247 



sporangia of the aspergillus niger. The growth of this latter 
is seldom as extensive as that of the other two varieties. A 
microscopic examination alone will enable us to distinguish 
with certainty between otomycosis and the milder forms of 
desquamative inflammation involving the canal. The greater 
consistency of the epithelial plug and the imbricated arrange- 
ment of the scales usually give the observer a hint as to the 
nature of the condition present. It is probable that in no 
case do these low forms of 
vegetable life take root upon a 
perfectly healthy cutaneous sur- 
face ; it is necessary that the 
epithelium should be wanting 
over a small area at least, in 
order that the plant may de- 
velop. Hence it is, that para- 
sitic inflammation of the mea- 
tus is usually coexistent with 
some condition of the external 
canal or of the middle ear char- 
acterized by the presence of 
moisture. The epithelium of 
the canal is thus softened and 
thrown off, leaving a surface 
which forms an excellent site 
for the development of a low form of plant life, the growth 
being stimulated at the same time by the presence of moisture. 
The mere presence of aspergillus spores in any aggregation 
of foreign matter which may be removed from the meatus does 
not warrant a diagnosis of parasitic inflammation of the canal, 
since it is usual to find them in ceruminous masses, or upon 
any foreign body which has remained in the canal for a con- 
siderable length of time. It is only when they constitute the 
bulk of the mass that this constitutes a lesion proper. 

The diagnosis of the desquamative form of inflammation 
will be based upon the presence in the deep meatus, of a com- 
pact mass, whitish in color, which, although easily penetrated 
by the probe or curette, is removed with considerable diffi- 
culty. The walls of the canal are ordinarily moist and pre- 
sent a sodden appearance, the superficial epithelium being 
easily wiped off by means of the cotton pledget, which, upon 
investigation, is found to be covered with thin white flakes of 




Fig. 86. — Aspergillus flavus. 
G, Sporangium ; H, Hypha. (Gruber.) 



248 DIFFUSE EXTERNAL OTITIS. 

irregular size and shape. If the probe is immersed in water 
these are seen to spread out and float upon the surface, but 
are not dissolved by the fluid ; they are really the epidermal 
cells lining the canal, which have been thrown off by the in- 
flammatory process. The obstructing mass is an aggregation 
of these cells, and, though easily penetrated by any instru- 
ment, which may remove a considerable quantity each time 
it is inserted, is very difficult to remove completely. Even 
when the fundus seems entirely clear we often find, in at- 
tempting to dry the parts perfectly, that the cotton pledget 
brings away more of these white scales, so that the complete 
clearing out of the meatus is a matter of no small difficulty. 
The entire epithelial plug presents an appearance not unlike 
a wad of unsized paper that has been moistened in water, ^nd, 
in fact, is often mistaken for a foreign body of this kind, which 
has found its way into the canal. 

Where the inflammation is of what may be called the 
symptomatic type — that is, merely an indication of a deeper- 
seated inflammatory process within the mastoid — we usually 
find that the superior and posterior walls of the canal close to 
the membrana tympani are most involved. The canal lumen 
at its deepest part is narrowed by an apparent sinking of the 
walls, and at the fundus, instead of a well-defined line of de- 
marcation between the drum membrane and canal walls, it ap- 
pears as if the superior and inferior walls were separated only 
by a narrow slit, through which a small area of the membrane 
is seen. The chief point of diagnostic importance is the dif- 
ference between this condition and that seen in circumscribed 
otitis externa. In this latter form, after the speculum has been 
introduced into the canal, the membrana tympani is distinctly 
seen, and appears normal in extent as the obstruction lies near 
the orifice of the meatus. In the disease under consideration 
the introduction of the speculum is easy, but the canal be- 
comes more obstructed as we approach the fundus, owing to 
the fact that the disease is a periostitis of the deeper part of 
the canal (Fig. 78). It is of extreme importance, especially in ' 
children, to recognize this condition early, as it is one of the 
best indications that a previously existing middle-ear inflam- 
mation has involved the deeper structures, or that an accumu- 
lation of pus in the tympanum has passed out through the 
Rivinian fissure along the superior and posterior aspects of 
the meatus (Fig. 87). In either case the condition is one 



PROGNOSIS. 



249 




which requires prompt treatment in order that serious con- 
sequences may be averted. The appearance presented by a 
chronic diffuse otitis, resulting in either uniform narrowing of 
the meatus or isolated bony 
deposits or exostoses, offers 
no difficulties in diagnosis. 
When the latter condition is 
present, care need only be 
taken to so cleanse the parts 
that the observer may be cer- 
tain that the localized en- 
croachment upon the lumen 
of the canal is beneath the 
integument instead of super- 
ficial to it. It would seem al- 
most impossible for this mis- 
take to be made, but masses of 
hardened cerumen occasion- 
ally present the appearance 
of an exostosis, the surface of 
which is covered by a thin 
layer of cerumen. By means 
of the curette any foreign substance is easily removed from the 
canal wall, and the true condition becomes apparent at once. 

Prognosis. — The course pursued by the disease we are 
here considering is as varied as the causes which underlie it. 
The simpler varieties are unattended by any grave results, al- 
though somewhat obstinate to relieve. Where the deeper 
parts are involved, where the disease is of long standing, or 
where the condition is symptomatic, the prognosis is fre- 
quently grave. Important regions may suffer secondarily, 
by extension directly from the canal, or the condition with- 
in the meatus may, if unchecked, spread to the middle ear 
and result in any of the sequelae of a severe inflammation with- 
in the tympanum. Where the disease is secondary to an in- 
tratympanic affection the gravity of the prognosis depends 
more upon the condition of the middle ear than upon the 
changes within the canal. As regards the impairment of 
function, the power of audition may suffer either from the 
narrowing of the meatus throughout its entire extent or by 
the development of circumscribed bony deposits. In some 
instances the chronic congestion of the deeper structures 



Fig. 87. — Appearance observed in infancy 
when fluid from the tympanum escapes 
through the Rivinian fissure. (Nat- 
ural size.) 



250 DIFFUSE EXTERNAL OTITIS. 

caused by a chronic inflammatory process within the mea- 
tus, may lead to functional impairment. In the desquama- 
tive form of inflammation the pressure exerted by a mass of 
epithelium may produce fatal results by absorption of the 
bony walls and exposure of the cranial contents. This may 
occur without any symptoms of middle-ear inflammation, or 
the membrana tympani may be destroyed and a suppurative 
otitis media result. Sometimes the mass, while not leading to 
such grave results, seriously impairs the function of the ear 
by chronic adhesive processes within the tympanum from the 
long-continued pressure. In other cases the pressure causes 
labyrinthine changes. 

Treatment. — In the mild cases of chronic diffuse otitis 
externa treatment is largely directed to the relief of the dis- 
tressing pruritus from which the patient suffers. The crusts 
arising either from involvement of the sebaceous glands in 
seborrhcea or from cutaneous infiltration in eczema should 
be removed by some bland oily application, such as vaseline 
or olive oil, after which, in the glandular variety of the dis- 
ease, it will be sufficient to apply once each day a slightly 
stimulating ointment, such as the unguent, hydrarg. ammoniat., 
diluted with ten parts of vaseline or cold cream, or the un- 
guent, hydrarg. oxidi flavi may be employed in about the 
same strength. In eczema the various measures detailed 
under eczema of the auricle will be found valuable. It is im- 
portant, in order that the treatment may be efficacious, that 
the patient should refrain from scratching the ears, as this 
increases the local inflammation. For this purpose we may 
add either cocaine or morphine to the above ointments. It 
is well for these patients on retiring to insert into the ear a 
pledget of cotton smeared with such an ointment, as they 
frequently injure the parts during sleep. The use of water in 
any inflammatory condition of the canal attended with infil- 
tration of the integument is to be absolutely forbidden, as it 
tends to increase its activity. 

In the parasitic variety the fungus should be removed as 
completely as possible by means of the curette, forceps and 
cotton pledget, great care being taken to avoid abrading the 
epidermis of the canal. In these cases the walls of the mea- 
tus will be found very sensitive, and the complete removal of 
the parasite will be difficult. The occasional application of a 
ten per cent, solution of cocaine during the operation will af- 



TREATMENT. 251 

ford considerable relief and will facilitate the operation. It 
is not well to prolong unduly our efforts at removal or to in- 
flict severe pain. After as much as possible has been removed 
a solution of bichloride of mercury, one to eight thousand, in 
fifty per cent alcohol, or a saturated alcoholic solution of bo- 
racic acid, or a two-per-cent alcoholic solution of salicylic 
acid, as Siebenmann* recommends, should be applied to the 
parts by means of the cotton pledget. 

It is sometimes well to employ a powder instead of the 
above solutions. The walls of the canal may be lightly dusted 
with boracic acid or a mixture of boracic acid and salicylic 
acid in the proportion of twenty to one. In this way we 
avoid the presence of moisture, a condition which we know 
favors the growth of the fungus. It is well to see the patient 
daily at first, and at each sitting to remove as much of the 
deposit as possible. When the canal seems free the antisep- 
tic solution should be placed in the hands of the patient, and 
he should be directed to instill ten or twelve drops of either 
preparation into the canal twice or three times daily. By 
this means any new growth is prevented and a complete cure 
effected. Remembering that an otomycosis is often depend- 
ent upon a suppurative inflammation of the middle ear, it is 
scarcely necessary to state that this affection, if present, must 
be treated properly in order to prevent the recurrence of the 
condition. 

Prophylactic measures against development of organisms 
within the meatus should be taken in all cases of aural disease 
which come under the observation of the surgeon. A com- 
mon cause of the milder varieties of this affection depends 
upon a habit so common among the laity of instilling oily so- 
lutions into the ear for the relief of pain. Not only should 
this be forbidden, but the surgeon should be particularly care- 
ful in cases where it is necessary to use oily substances within 
the meatus that none of the fatty material remains in the canal 
when the patient is discharged. To be certain of this it is ad- 
visable upon dismissing the patient to wipe the canal thor- 
oughly with a cotton pledget moistened in alcohol. 

In the desquamative form, the first indication is to remove 
the mass of epithelium filling the canal. This is by no means 
simple where the disease has persisted for a long time, espe- 

*Arch. of Otol., vol. xviii, p. 235. 



252 



DIFFUSE EXTERNAL OTITIS. 



cially as attention is frequently drawn to the condition for the 
first time by an acute inflammation of the parts, resulting in 
so much swelling that the calibre of the canal is greatly 
reduced. 

Our first efforts at removal should be by the use of a warm 
antiseptic solution injected into the ear by means of the syringe. 
This will usually bring away the superficial portion of the 
mass, and occasionally all of it. Frequently, however, the 
deeper portion of the canal remains obstructed, and it will be 
necessary to use the blunt curette in order completely to re- 
move the collection. When the canal is swollen and tender, 
as frequently occurs from an acute exacerbation, the manipu- 
lation is extremely difficult, and sometimes a general anaes- 
thetic is necessary. In using the curette, w r e should first at- 
tempt to separate the mass from the canal along one wall, 
and afterward break it up by inserting the instrument be- 
tween it and the canal wall and removing small portions suc- 
cessively until a narrow channel has been made between the 
canal wall and the foreign body. By directing the stream of 
water from the syringe toward this channel, the entire mass 
may usually be brought away, although it may be necessary 
to remove the entire collection piecemeal with the curette. 
If it is impossible to insert the curette between the epithelial 
aggregation and the canal wall at any point, owing to the ten- 
derness of the meatus, our efforts are sometimes more success- 
ful if a passage is tunneled directly through the centre of the 
plug, after which, by carrying the curette into this channel 
and then pressing it in toward the opposite wall of the canal, 
the portion included between the instrument and the wall 
may be removed ; the process must be repeated until the mea- 
tus is perfectly clear. 

Where the condition has remained unrecognized for a long 
time, the bony meatus close to the drum membrane may be 
very much dilated, and the foreign body attain such dimen- 
sions as to render its removal from the meatus in its entirety 
impossible. At the same time the deep meatus has been so 
dilated that the manipulation of any instrument, such as the 
curette or a spoon, is very much restricted. These epithelial 
masses may invade the cells of the mastoid process through 
the absorption or necrosis of the bony walls from pressure. 
It occasionally becomes necessary to open the mastoid in 
order completely to eradicate the disease. Such cases have 



TREATMENT 



253 



been reported, but an element of doubt always remains as to 
whether they were not cases of cholesteatoma originating 
within the tympanum and invading the canal secondarily. 

After the canal has been thoroughly cleared, our efforts 
should next be directed toward putting the epidermis in 
normal condition. Here powders are of special benefit, as 
they relieve the sodden condition of the parts more quickly 
than do fluid preparations. For this purpose boracic acid 
may be dusted over the walls of the canal, or a mixture of 
boracic acid and iodoform, or iodol, if the odor of iodoform 
is objectionable. Quite recently the introduction of dermatol 
into surgery has given us a drug particularly adapted to these 
cases. These measures should not be trusted to the hands 
of the patient, but should be carried out by the surgeon — at 
first daily, the interval being increased as the case progresses. 
The oxide of zinc mixed with boric acid, in the proportion 
of one part of oxide of zinc to two of boric acid, may also 
be used tvith advantage in the milder forms of the disease. 
When necrosis has occurred it will first be necessary to re- 
move the dead bone, after which the case may be managed 
on general surgical principles. If granulation tissue develops, 
a thorough cleansing of the parts may be sufficient to cause 
it to disappear ; if large in amount, it should be removed 
by means of the cold snare or destroyed in situ by the gal- 
vano-cautery, nitrate of silver, or chromic acid. The last 
agent yields better results and is more easily manipulated 
than the others. 

Where the disease is of the symptomatic variety much 
more energetic measures must be undertaken, and if the pain 
is intense, cold applications to the mastoid process are indi- 
cated. This is most easily effected by using the Leiter coil 
(Fig. 81) or the aural ice bag (Fig. 70). The local abstrac- 
tion of blood by means of the artificial leech may also give 
relief where the pain is very severe. It is to be applied be- 
hind the ear over the mastoid process, since the symptomatic 
variety is indicative of the fact that this region is affected. 
From a healthy adult from two to four ounces of blood may 
be removed ; and in the very early stages this plan of local 
bloodletting, followed by the application of cold, may pre- 
vent further progress. If this fails, or if the condition has 
advanced too far to be aborted, a long deep incision should 
be made through the tumefied tissues which are seen to 



254 DIFFUSE EXTERNAL OTITIS. 

encroach upon the lumen of the canal close to the membrana 
tympani. This incision completely divides the soft parts 
down to the bone. The short curved bistoury is carried into 
the canal as far as the drum membrane, and is plunged 
quickly into the bulging supero-posterior wall until the point 
is felt to impinge upon the bone ; it is then drawn outward, 
the point still being pressed firmly upon the bone. In this 
way the periosteum is divided and tension relieved. The in- 
cision should not be less than half an inch in length, and may 
be even longer ; the bleeding is very free, a fact which con- 
tributes largely to the benefit derived. It is to be borne in 
mind that the external otitis here is a manifestation of an 
inflammatory process within the upper part of the tympanum 
itself. We are therefore, in making the initial puncture, to 
carry the knife upward, backward, and inward beyond the 
inner extremity of the bony canal, through the membrana 
flaccida, into the tympanic vault (Fig. 87). The incision is 
completed in the manner above described by drawing the 
knife outward along the supero-posterior wall of the meatus. 
In this way the mucous folds within the tympanum are di- 
vided, and the congestion within the middle ear reduced. 
Where the tumefaction in the canal is due to the presence of 
pus, evacuation through the meatus is not sufficient, and it is 
imperative that the mastoid cells should be at once opened 
and every vestige of diseased bone removed. 

Where the inflammation has led to a diminution in the 
calibre of the meatus through hypertrophy of the bony walls, 
it is sometimes necessary, in order that the function of the 
organ may be preserved, to attempt a restoration of the 
channel to its normal size. When a very small passage re- 
mains, gradual dilatation, if systematically carried out for a 
long time, may prove satisfactory. This is best accomplished 
by inserting into the canal a small aluminium tube, which will 
just pass through the constriction. The patient is to wear this 
for one or two days, when it is to be removed and a little 
larger tube inserted. It is seldom possible, however, to 
promise that the tube may ever be dispensed with perma- 
nently, for when it is removed the parts very quickly resume 
their original position. The diameter of the meatus may be 
very considerably increased by carrying out this treatment, 
and the patient should learn to insert the tube himself, wear- 
ing it during the day and removing it at night. Its presence 



ACUTE DIFFUSE EXTERNAL OTITIS. 255 

causes no inconvenience, and effectually relieves the impair- 
ment of hearing- due to the diminished size of the passage. 
Pomeroy has suggested the use of small rubber tubes stretched 
over a silver probe to. enable them to be inserted through the 
stricture. After they have been properly placed the probe is 
withdrawn and the tube resumes its original dimensions, thus 
exerting by its elasticity a constant dilating force against the 
surrounding walls. This plan has proved advantageous in 
some cases, but relapses have taken place, even after the con- 
dition was apparently cured. Where the channel is so nar- 
row that only a fine probe can be passed, and the use of a 
tube is impossible, it is well, for the first few days, to carry 
a very small, tightly wound pledget of cotton through the 
constriction by means of the forceps ; this cotton pledget ab- 
sorbs moisture from the walls of the canal, increases in size, 
and dilates the passage slightly. In this way sufficient space 
may be gained to permit the insertion of a small tube, after 
which one of the plans already described may be carried out. 
The removal of any portion of the bony wall by means of 
cutting instruments is seldom attended by good results where 
the narrowing is symmetrical. If the passage is encroached 
upon by an exostosis, this may be removed. This condition 
will be treated in a later chapter. 

Acute Diffuse External Otitis. 

etiology. — The acute form of the disease usually occurs 
as an exacerbation of a previous chronic condition ; occasion- 
ally, however, it presents as an idiopathic disease, either from 
exposure to cold or as a complication of some profound con- 
stitutional infection, as epidemic influenza, scarlet fever, typhus 
and typhoid fevers, etc. The most frequent cause is a puru- 
lent otitis media, the tissues of the canal becoming infected by 
the purulent discharge in which they are bathed. This last va- 
riety does not include those cases already denominated under 
the term symptomatic. Injuries of the canal from mechanical 
violence or from the action of the potential or chemical escha- 
rotic agents may also give rise to an acute diffuse inflamma- 
tion of the parts. An occasional cause is the occurrence of a 
furuncle in the meatus, the condition becoming general and 
involving the entire canal after the circumscribed process has 
fully developed. 

Pathology. — The changes consist in a diffuse inflammation 



256 DIFFUSE EXTERNAL OTITIS. 

of the cellular tissue of the walls of the meatus. In the first 
stage the parts are intensely congested, after which there is a 
free transudation of the fluid elements of the blood, causing 
oedema ; the interstices between the connective-tissue fibres 
become infiltrated with new cells, and if allowed to continue 
unchecked pus formation results. It is seldom, however, that 
this occurs, as relief is sought before this stage is reached. 
The tissues break down in this region at a very late period, 
on account of their density and firmness, and remain infiltrated 
for a long period before local necrosis results. 

Symptomatology. — The subjective symptoms are pro- 
nounced and succeed each other rapidly. The first sensation 
is one of fullness or discomfort in the canal, quickly followed 
by intense pain. The constitutional disturbance is .frequently 
quite marked, the temperature being elevated from two to 
three degrees above normal ; considerable prostration is pres- 
ent ; the patient suffers from headache, loss of appetite, and all 
those symptoms indicative of an inflammatory process in dense 
cellular tissue. From the swelling of the parts the meatus is 
rapidly occluded and the function of audition is markedly in- 
terfered with. Subjective noises are often present, but the 
pain is so severe that they are seldom complained of. In ad- 
dition to the spontaneous pain intense pain is elicited upon 
touching the auricle. After a short period the surrounding 
lymphatic glands may become infiltrated, especially those ly- 
ing immediately behind and below the auricle, any movement 
of the jaws is painful, and in severe cases the mouth is opened 
with difficulty. 

Diagnosis.-— We have to differentiate between a circum- 
scribed inflammation of the meatus, an acute affection of the 
middle ear and mastoid, and the disease under consideration. 
The symptoms complained of by the patient do not differ, ex- 
cept in severity, from those characteristic of the circumscribed 
external otitis. The constitutional disturbance, however, is 
much more marked and the progress of the disease more rapid. 
The insertion of the speculum ordinarily causes but little 
pain and the outer third of the meatus is often found to be 
nearly normal in size. Deeper, however, the lumen is much 
diminished, the encroachment usually being from the supero- 
posterior wall, which seems to project downward and for- 
ward into the canal. The swelling is more pronounced as 
we approach the fundus and a considerable portion of the 



DIAGNOSIS. 



257 



drum membrane is hidden from view. Where the membrana 
tympani lies very obliquely to the superior and posterior walls 
it apparently merges into these without any line of demarca- 
tion. This is particularly the case in infants, owing to the ab- 
sence of the bony meatus ; in the adult, however, if the canal 
alone is involved the observer recognizes that a portion of the 
drum membrane is concealed from view, but that the swollen 
wall of the canal is not continuous with the membrana tym- 
pani (Fig. 88). A sulcus can be recognized between the mem- 
brana tympani and the tumefaction. In very severe cases 
the swelling may be so great as to occlude the meatus com- 
pletely, the opposite walls lying in contact. The surface of 
the tumefaction is slightly 
moist, presenting a dead- 
white color, due to the local 
necrosis of the superficial 
epithelial cells. If these are 
wiped away the surface ap- 
pears reddened and moist. 
This desquamation of the 
superficial cells is often a 
very prominent feature of 
the disease and may render 
the diagnosis extremely dif- 
ficult. These cells, as they 

are rapidly Cast off, aCCUmu- Fig. 8S.— Acute diffuse external otitis, in- 
late in the canal and, owing y° lvin s , P ost 7° - superior canal wall. 

& (Natural size.) 

to its contracted calibre, are 

with great difficulty cleared away so as to permit a view of 
the small portion of the drum membrane not hidden by the 
swollen canal wall. The swelling is intensely painful to ma- 
nipulation with the probe; pressure in front of the tragus or 
efforts at crowding the canal upward or forward are attended 
with severe pain. There may be considerable oedema over the 
post-auricular region, and the auricle may be displaced out- 
ward and forward from the side of the head more or less 
prominently. Palpation along the anterior border of the 
sterno-mastoid muscle reveals considerable infiltration of the 
lymphatic glands. When this condition occurs with oedema 
over the mastoid the differential diagnosis between diffuse ex- 
ternal otitis and perforation at the tip of the mastoid is possi- 
ble only by speculum examination alone. It is exceedingly 
18 




258 DIFFUSE EXTERNAL OTITIS. 

important in these cases to prolong the speculum examination 
sufficiently to determine the coexistence of any inflammatory 
condition within the tympanum. This is particularly true in 
the case of children, since an acute purulent otitis media, if 
severe, may be accompanied by a diffuse inflammation in the 
external meatus, and the early recognition of the true nature 
of the disease is a matter of great importance. The surgeon 
should therefore obtain a view of the drum membrane, al- 
though this may require considerable time and inflict a certain 
amount of suffering upon the patient. Where the parts are 
very much swollen and the view is obstructed by desquamated 
epithelium, the persistent use of small cotton-tipped probes 
will enable us to clear this away, and to reduce the swelling 
by pressure sufficiently to permit an inspection of the drum 
membrane, or at least of a portion of it. If this is normal in 
color we are warranted in the assumption that the disease is 
confined to the canal alone. 

Prognosis. — The progress of the affection will depend 
largely upon the causation. If it is idiopathic the prognosis 
is good ; if dependent upon traumatism, either mechanical, 
chemical, or thermal, the outcome will depend upon the se- 
verity of the injury inflicted. As complicating an acute or 
chronic process within the middle ear the severity of the lesion 
within the tympanum furnishes an index of the probable out- 
come of the case. When arising from a previous chronic in- 
flammation of the canal without any special exciting cause, the 
disease is usually mild in character. The degree of constitu- 
tional disturbance does not indicate the probable severity of 
the attack, as in the early stages ; the general symptoms are 
usually very well marked even in mild cases. 

Treatment. — The first efforts should be directed toward 
relieving the severe pain which the patient suffers, and the 
attempt should be made possible to abort the process before 
the stage of pus formation is reached. For the relief of pain, 
both local and general measures are indicated. A sufficiently 
large dose of morphine or some preparation of opium should 
be administered, either by the mouth or, if the severity of the 
attack demands it, by the hypodermic method. The patient 
should be confined to bed and kept as quiet as possible ; it is 
also well to obtain a certain amount of revulsive action by 
the administration of a saline cathartic. If seen very early, 
we may resort to local bloodletting, removing, by means of 



TREATMENT. 



259 



the artificial leech, not less than two ounces of blood. The 
site from which this is removed will depend somewhat upon 
the region in which the process seems to be most severe, but 
as a rule in the diffuse form of inflammation the best results 
are obtained by the abstraction of blood from the mastoid 
region ; here preference should be given to the artificial 
leach rather than to the natural. Immediately after the ab- 
straction of blood the Leiter coil should be applied to the 
mastoid region, or the aural ice bag may be used if this is 
more agreeable to the patient. If for any reason local de- 
pletion seems inadvisable, we may proceed at once to apply 
the ice coil or ice bag. In addition to this, considerable re- 
lief is often obtained by frequently irrigating the canal by 
means of the ear syringe, or, better, by employing the foun- 
tain syringe. A weak antiseptic solution, as of bichloride of 
mercury, one to eight thousand, or a saturated aqueous solu- 
tion of boric acid, is to be used for this purpose. The warm 
fluid should be allowed to flow into the meatus for a period 
of from five to fifteen minutes, according to the relief which 
it affords. In this manner the parts are cleansed and the 
analgesic effect of the warm douche obtained. It is not neces- 
sary to remove the ice coil from the mastoid region in-order 
to carry out this measure, and although the two would seem 
to be apparently opposite in action, the effect obtained is 
often very satisfactory. This plan of treatment should not 
be persisted in for more than twenty-four hours, at the end 
of which time, if the symptoms are not so much relieved that 
the patient is able to rest without the use of an opiate, and 
complains of but little or no spontaneous pain, more active 
measures are demanded. At this period no treatment, to my 
mind, is so efficacious as a deep free incision in the canal, 
relieving at the same time the tension of the parts and effect- 
ing local depletion. In order to be efficacious, the incision 
should be deep and of considerable length. The site of elec- 
tion is usually the posterior or postero-superior wall of the 
canal. Under illumination by means of the head mirror, a 
sharp stout knife, such as is shown in Fig. 87, should be carried 
through the swollen canal wall, close to the drum membrane, 
until the point of the instrument is felt to impinge upon the 
bone. The incision is then extended directly outward for 
from one half to three fourths of an inch, dividing all the over- 
lying structures, the point of the knife being kept in contact 



26o DIFFUSE EXTERNAL OTITIS. 

with the bone throughout the entire length of the incision. 
Although intensely painful, the relief afforded is almost im- 
mediate, and is complete usually at the end of twelve hours. 
Hartmann * strongly advises against incision in the acute 
form of diffuse external otitis, asserting that improvement 
never follows the procedure, while frequently the condition 
is much aggravated. Certainly this has not been my experi- 
ence, although I hesitate to differ with so high an authority. 
The onlv possibility of this measure inflicting injury would be, 
it seems to me, in cases where the field of operation had not 
been properly cleansed. If the canal is freely irrigated before 
the incision is made I can see no reason why the result should 
be anything but satisfactory. After the operation the ear is 
to be syringed every two to four hours with a mild antiseptic 
solution. This irrigation is to be continued until the local 
condition becomes normal, the frequency being diminished 
gradually. Complete resolution with restoration of the nor- 
mal calibre of the canal is frequently rather slow, and may 
not occur for several weeks. During this period the canal 
is apt to be the seat of a desquamative inflammation, the epi- 
thelium being rapidly thrown off, while at the same time a 
certain amount of serous transudation takes place, causing a 
thin turbid discharge from the canal. In this condition the 
meatus offers a favorable site for the development of asper- 
gillus, and our efforts at cleansing the parts should not cease 
until the discharge has entirely disappeared. For the first 
few davs the most relief will be obtained bv the use of one 
of the antiseptic solutions, the canal being cleansed from two 
to four times daily, according to the amount of discharge. 
After the discharge has ceased the use of any fluid in the 
canal rather prolongs the process, and the parts will more 
quickly return to their normal condition if the wails of the 
meatus are dusted lightly with some antiseptic or astringent 
powder, such as finely divided boric acid, oxide of zinc, der- 
matol, bismuth subnitrate. or any similar substance. If it is 
necessary to leave the treatment largely to the hands of the 
patient, alcoholic solutions may be used in place of powders. 
Of these, a four- or eight-per-cent solution of boric acid in 
dilute alcohol is probably the most efficacious. If the dis- 
charge continues, after the use of the powders and upon 

* Krankheiten des Ohres, Berlin, 1SS9, p. 99, 



CROUPOUS AND DIPHTHERITIC EXTERNAL OTITIS. 2 6l 

thoroughly drying- the ear by means of the cotton pledget, 
we find that the cutaneous surface is reddened and moist, a 
stimulating application, such as a solution of nitrate of silver, 
lightly brushed over the canal will frequently cause the walls 
to return rapidly to their normal condition. In making these 
applications a comparatively mild solution (about ten grains 
to the ounce) should be used at first, the strength being grad- 
ually increased according to the indications. These applica- 
tions may at first be made daily, and afterward at longer inter- 
vals. If the disease is not seen in its early stages and, in spite 
of our efforts, there is considerable destruction of tissue, the 
affection may result in a perichondritis of the auricle, with 
partial necrosis of the cartilaginous framework. The treat- 
ment of this affection has already been considered. If our 
efforts to limit the pathological process to the soft parts are 
unsuccessful and there is an involvement of the underlying 
osseous structures, the case is to be dealt with according to 
the rules laid down for the management of acute inflamma- 
tion of the mastoid process. 

In every case of acute inflammation of the external 
meatus it is to be remembered that so long as we confine the 
process to the canal walls we have an affection, the manage- 
ment of which is comparatively simple. The danger is that 
it may either extend to the bony or cartilaginous structures, 
on one hand, or may involve the tympanic cavity secondarily, 
in which case we have to deal with a suppurative process 
within the middle ear. Moreover, where extension to the 
tympanum occurs, it is the upper part of the cavity which is 
involved. As this portion of the tvmpanum is richly sup- 
plied with cellular tissue, the complication constitutes a men- 
ace to life. 

Croupous and Diphtheritic External Otitis. 

The diseases included under the above heading constitute, 
in reality, but minor subdivisions of diffuse external otitis. 
Since the epidermis covering the meatus differs in no respect 
from that covering other portions of the body, we have no « 
reason to presume that it should be exempt from the above 
special types of inflammation. Under favorable conditions 
the germ either of croupous or of diphtheritic inflammation 
may find lodgment within the meatus and produce there its 
characteristic exudation. The croupous form is less com- 



262 DIFFUSE EXTERNAL OTITIS. 

monly observed than the diphtheritic. Like a croupous in- 
flammation in other portions of the body, it is characterized 
by a white, thick, velvety deposit on the surface of the mem- 
brane involved, consisting- of coagulated fibrin containing 
within its meshes white blood corpuscles. This deposit lies 
immediately upon the surface, and can. be detached from the 
underlying structures without the rupture of blood vessels. 
It is probable that certain conditions of the general health 
render the patient particularly prone to this form of inflam- 
mation. The condition known as hy perinosis, or an increase 
in the fibrin elements in the blood, is undoubtedly the chief 
predisposing factor. Given this general condition, and a 
simple inflammation of the epidermis lining the meatus, the 
lodgment of the specific germ of croupous inflammation will 
ordinarily be followed by a change from the simple type to 
the croupous form. 

The diphtheritic form, on the contrary, is most frequently 
observed as a complication of otitis media, dependent upon 
either a diphtheritic inflammation of the fauces or the angina 
of scarlatina, although it occasionally occurs as a primary 
affection. When occurring as a complicating lesion, the 
source of infection is usually the middle ear ; a purulent in- 
flammation here, with subsequent rupture of the membrana 
tympani, being followed by a purulent discharge which con- 
tains the specific diphtheritic germ. Such an otitis media is 
accompanied by a diffuse external otitis in most cases. The 
external meatus is therefore in a condition favorable to the 
lodgment and development of the diphtheritic germ. 

The physical examination reveals, in the early stages, the 
walls of the meatus covered with a white deposit, or, if ob- 
served only in the period of necrosis, with a grayish-white 
membrane, which is firmly attached to the underlying skin, 
and can be removed only by the use of considerable force, the 
removal being attended with the rupture of blood vessels. 
When spontaneous exfoliation has taken place, the exposed 
areas show a loss not only of the superficial epithelium, but 
also of the deeper layers, the condition being one of true 
ulceration. The fibrous structures of the cutis are also affect- 
ed, becoming swollen and encroaching markedly upon the 
lumen of the passage. The condition, whether of primary or 
secondary origin, presents the same picture, and its recogni- 
tion is not difficult. It might be confounded with croupous 



TREATMENT. 263 

inflammation, but if we bear in mind that a croupous deposit 
separates from the underlying parts without haemorrhage, the 
mistake need not be made. The severe type of desquamative 
inflammation of the canal, either occurring primarily or de- 
pendent upon an otitis media purulenta, may also lead to 
error. Here, however, the deposit is not membranous, but 
consists simply of necrotic epithelial cells superimposed upon 
each other. There is no destruction of tissue, and upon re- 
moval no ulceration remains. In the same way an aspergillus 
within the canal may be mistaken for a diphtheritic inflam- 
mation, but the microscope will easily reveal the true charac- 
ter of the disease. The history of the case will also enable a 
differentiation to be made between the various conditions. 

The presence of a croupous or diphtheritic deposit in the 
external canal, when occurring as a secondary disease, is usu- 
ally no serious matter, since the surface presented for the 
absorption of the toxine of the diphtheria bacillus is one 
through which this takes place very slowly ordinarily. In 
cases where the diphtheritic deposit in the canal is but a sec- 
ondary feature of the general infection the outcome depends 
upon the severity of the original disease without reference to 
the local manifestation in the auditory meatus. Occasionally 
such deposits occur primarily, the germ gaining access to the 
external canal in some unknown way, and taking root there 
upon an abraded surface which has resulted from a traumatic 
or other cause. In such instances only very slight constitu- 
tional symptoms are apt to be present, and the danger to be 
feared most is that the inflammation of the external canal may 
extend inward and involve the tympanum, the mucous lining 
of which would permit general infection more easily than 
would cutaneous lining of the canal. Croupous deposits are 
of trivial importance aside from the local pain which is pres- 
ent, and this is no more severe than in simple diffuse inflam- 
mation. 

Treatment. — The treatment of the local condition consists 
in the thorough and frequent cleansing of the surface involved 
to prevent the membrane from spreading by contiguity of 
structure, thus increasing the extent of the surface through 
which the poison may enter the circulation. A diphtheritic 
membrane in any situation will be exfoliated spontaneously at 
the end of from three to eight days. If removed by violence 
before this time, blood vessels are opened, and the raw surface 



264 DIFFUSE EXTERNAL OTITIS. 

becomes covered very quickly by a new deposit, while the 
laceration of the vessels rather favors the absorption of the 
poison. It is wise, therefore, to confine our efforts to keeping 
the parts thoroughly cleansed, in this manner diminishing the 
activity of the germ, taking care that our efforts are not so 
vigorous as to excite any inflammatory reaction on the sur- 
rounding parts. To effect a thorough cleansing of the canal 
we may resort to the use of the ear syringe, or, perhaps bet- 
ter, the fountain syringe, employing a solution of lime water, 
which is allowed to flow into the canal for from five to ten 
minutes. In this way portions of the deposit already necrotic 
are removed, and a certain amount of solvent action is exerted 
upon the transudation which is still firmly attached to the 
parts beneath. Antiseptic solutions may be used here, the 
strength of the solution being somewhat greater than that 
employed for ordinary cleansing purposes. In this way the 
deposit is rendered inert, while at the same time, by its pres- 
ence, it protects the surface to which it is attached, and when 
it exfoliates spontaneously the denuded surfaces are protected 
by the presence of granulation tissue, which offers a barrier 
to local infection. 

In addition to irrigation, certain medicinal preparations 
may be applied to the deposit by means of the cotton applica- 
tor; of these, I think the solution of ferric sulphate in the full 
strength is by far the most efficacious. This causes a rapid 
necrosis of the superficial layers of the pseudo membrane, 
while at the same time it exerts no irritating action, even if 
it touches parts which have not yet become affected. This 
local necrosis inhibits or stops completely the growth of 
the germ, puttings an end both to its toxic effect upon the 
general system and to its further local propagation. A croup- 
ous exudate may be managed in exactly the same manner, its 
separation being more easily effected than one of a true diph- 
theritic character. In this form, after the iron solution has been 
applied, it is often possible to remove a considerable portion 
of the deposit by means of the forceps without inflicting any 
injury upon the cutaneous lining of the canal. The adminis- 
tration of constitutional remedies will be governed by the 
same rules which apply to similar deposits located in the 
fauces. Remembering that a croupous exudation has for its 
predisposing cause a certain blood condition, it is wise to ad- 
minister the tincture of the chloride of iron in large doses, 



HEMORRHAGIC EXTERNAL OTITIS. 



265 



with the hope of cutting short the attack. In the same man- 
ner a diphtheritic membrane appearing in the meatus, if ac- 
companied by the characteristic constitutional symptoms of 
septic infection, demands the free use of stimulants and such 
drugs as may be believed to mitigate the action of the poison. 
The various local complications do not differ from those al- 
ready mentioned under acute external otitis. 

Hemorrhagic External Otitis. 

Under this term Politzer* has described a disease of the 
external auditory meatus characterized by the presence of 
vesicles upon the walls of the canal. The inferior and anterior 
walls are usually the seat of the manifestation, although the 
other walls are occasionally affected. These vesicles are filled 
with a bloody fluid, and if allowed to remain, disappear spon- 
taneously at the end of a few days, their site being marked by 
an excoriated area. 

The disease may occur either as a primary affection or as 
a complication of an acute inflammatory process within the 
tympanum. The constitutional symptoms are very well 
marked, and consist of intense local pain, which frequently 
assumes a neuralgic character, spreading over the entire side 
of the head ; the temperature is elevated to from 99 to 102 , 
and there is a marked prostration ; occasionally delirium is 
present. The occurrence of this condition in the severe forms 
of tympanic inflammation which complicate constitutional dis- 
eases of the infectious type, particularly epidemic influenza, 
seems to show that the condition is indicative rather of a 
marked general infection than of any distinct local patho- 
logical process. In cases where we meet with this form of 
external otitis as an idiopathic disease, I am more inclined to 
consider it as either a tropho-neurosis similar in many re- 
spects to herpes, or, if the deeper layers of the canal are in- 
volved, as an accidental complication of a simple diffuse otitis. 
The latter view is that taken by Gruber,f and this seems to be 
entirely tenable. It is not improbable that the extravasation of 
blood cuts short the inflammatory process in the same manner 
as local depletion by artificial means, when the above measure 
is employed therapeutically in inflammation of the canal. 



* Lehrb. der Ohrenheilk., Stuttgart, 1893, p. 154. 
f Lehrb. der Ohrenheilk., Vienna, 1888, p. 289. 



266 DIFFUSE EXTERNAL OTITIS. 

Treatment. — The primary indication for treatment is to 
relieve the constitutional symptoms, the local condition being 
unimportant and requiring but little attention. The intense 
suffering must be relieved by the administration of free doses 
of morphine hypodermically. When the neurotic symptoms 
are well marked the administration of bromide of sodium 
in full doses will do much to render the patient more com- 
fortable. Complete rest should be insisted upon. The diet 
of the patient should consist mostly of fluids for the first 
twenty-four or forty-eight hours. The disturbance of the 
nervous system frequently brings about severe constipation, 
which in turn increases the severity of the local pain. It is 
well, therefore, early in the affection to administer calomel in 
small repeated doses until the effect upon the intestinal canal 
is obtained, its action being aided, if necessary, by a saline 
cathartic. Locally very little need be done, the condition 
within the canal being kept under observation in order that 
any tendency toward inflammation of the middle ear may be 
readily recognized and proper measures instituted to check it. 
If the vesicles are of considerable size they may be opened 
with a delicate knife, the walls of the vesicles being preserved 
as much as possible to protect the denuded areas within the 
canal. In case of spontaneous rupture the site of the vesicles 
may be lightly dusted with zinc oxide, lycopodium, bismuth, 
or any bland powder which will protect them until they are 
covered by normal epithelium. Occasionally these vesicles 
are located upon the tympanic membrane, in which event the 
pain is of unusual severity and the constitutional symptoms 
are correspondingly increased. In such cases it is wise to 
open the vesicles as soon as they appear, since almost imme- 
diate relief follows. Care should be taken that the canal is 
in a thoroughly aseptic condition before the operation, and 
the operator should guard against introducing the knife too 
deeply for fear of wounding the deeper layers of the drum 
membrane, and of opening into the tympanic cavity. The 
local tenderness renders manipulation difficult, and, unless 
the head is firmly held by an assistant, either of the above 
accidents is liable to occur. The sensitiveness of the region 
may be reduced somewhat by filling the canal with a ten-per- 
cent aqueous solution of cocaine about twenty minutes before 
the operation is to be performed. This solution must, of 
course, have been previously sterilized by boiling. 



CHAPTER XIII. 

IMPACTED CERUMEN. 

While constituting a condition which differs in no respect 
from that present when any foreign body is present in the 
meatus, this disease is of such common occurrence that it 
seems wise to consider it under a separate chapter. 

^Etiology. — The causes which lead to this condition de- 
pend either upon the production of an increased amount of 
the normal secretion of the ceruminous glands, or upon an 
interference with its regular discharge from the canal. In 
health cerumen is continually formed by the glands found in 
the meatus, and is discharged from the canal constantly, but 
in such small quantities that its presence is unnoticed. Any 
obstructive condition interfering with this process leads to 
an accumulation of the secretion within the meatus, and if it 
exists for a long period of time a considerable mass will ac- 
cumulate, varying in size and density according to the activity 
of the secretory process and the length of time that the ob- 
struction has existed. The conveyance of the product along 
the meatus is effected principally by the action of the jaws 
during mastication and speaking. With every motion at the 
intermaxillary articulation the anterior and inferior walls of 
the canal are moved, on account of the intimate relation be- 
tween the tragus and the capsular ligament of the articulation. 
This motion, when the canal is of normal size and shape, acts 
in such a manner that any foreign body within the fibrous 
meatus is moved constantly toward its orifice. If the canal 
presents certains anomalies in curvature or if the orifice is 
very narrow, the force may have exactly the reverse effect, 
and any body lying within the passage may be carried in the 
opposite direction — that is, deeper and deeper into the canal 
toward the drum membrane. If a small mass of cerumen 
collects in the canal its mere presence causes an increased 
amount of secretion from the glands lying in the immediate 

(267) 



268 IMPACTED CERUMEN. 

vicinity, while, at the same time, it acts as an obstruction to 
the outward passage of the product of the glands lying deeper 
within the channel. 

Although the causes stated are those most frequently 
operative in the production of the impaction of cerumen, it 
must be remembered that the secretory power of any gland 
may be modified by interference with its nerve supply. Under 
certain conditions we are warranted in considering that the 
disease is of a tropho-neurotic character. It is certain that 
the opposite condition, or one in which the cerumen is dimin- 
ished in quantity is frequently encountered in proliferous in- 
flammation of the middle ear. Proliferous otitis media fre- 
quently depends upon some perversion of the trophic nerve 
supply, and we are warranted in assuming that an increased 
amount of cerumen may occasionally occur from tropho- 
neurotic causes. 

Pathology. — Upon removal of these masses from the mea- 
tus they are found to contain not only the oily substance which 
is normally secreted by the parts, but also certain vegetable 
spores, the presence of which is purely accidental. The mass 
is occasionally covered by desquamated epithelium, while not 
infrequently we find in the centre a foreign body which has 
found its way into the meatus at some time and has formed 
a nucleus, about which the normal secretion has collected. 

This description applies to the simple cases of impacted 
cerumen. When, however, the masses attain considerable 
size the pathological process is more complex, and there is 
in addition a chronic desquamative inflammation of the deep 
canal dependent upon the presence of the foreign body. 
For the same reason the glands are probably stimulated to 
increased activity. As long as the mass consists of cerumen 
only, no considerable changes are wrought upon the bony 
walls of the passage ; when added to this, however, an inflam- 
mation of the desquamative type is set up by the presence of 
this foreign body, the osseous walls may be partially de- 
stroyed or the deep part of the canal may be enormously 
dilated. This is especially prone to take place in the region 
of the posterior wall, and the pneumatic spaces of the mastoid 
are obliterated. In some instances a chronic osteitis is devel- 
oped by the pressure, and the mastoid cells not only disap- 
pear, but the entire process becomes sclerosed and of ivory- 
like hardness. The membrana tympani may be perforated by 



SYMPTOMATOLOGY. 



269 



the pressure, and the removal of the mass may then reveal 
extensive pathological changes within the middle ear. 

Symptomatology. — The symptoms dependent upon the 
condition vary with the size of the mass, with its location, and 
with the amount of secondary inflammation which its presence 
has excited. The lumen of the meatus may be encroached 
upon to a considerable extent without any noticeable impair- 
ment of the auditory function, or without the appearance of 
any subjective symptoms, such as tinnitus, autophony, or a 
feeling as if the canal were stopped. On the other hand, a 
very small mass may be so situated as to give rise to promi- 
nent symptoms. If it is in such a position that the membrana 
tympani is pressed upon, the subjective symptoms are apt to 
occur early, and the function of the organ may be appreci- 
ably interfered with, even though the mass be small. Again, 
a large collection of cerumen may lie in the cartilaginous 
meatus and almost completely occlude its lumen without 
causing any symptoms referable to the ear. Frequently the 
first intimation of any trouble will be the occurrence of sud- 
den impairment of hearing following a plunge bath, when, 
on coming out of the water, the ear feels " stuffy " and full. 
These sensations are at first attributed to the presence of 
water in the canal. The efforts of the patient to remove 
this failing to relieve the discomfort, he seeks advice, and an 
examination reveals the presence of a mass which, from its 
size, must have been in the canal for a considerable period 
of time. The sudden access of the symptoms is due to the 
displacement of the plug by the water which has entered 
the meatus, causing it to assume a position where it com- 
pletely obstructs the passage. In other cases the patient be- 
comes conscious that the power of hearing is gradually but 
constantly diminishing ; coexistent with this impairment of 
function subjective noises make their appearance, at first 
causing but little annoyance, but subsequently becoming so 
loud and persistent as to cause him to seek relief. Where 
the occlusion is marked the patient often complains of au- 
tophony, hearing his own voice as if it came from within 
the head. This symptom is particularly marked w r here the 
affection is confined to one side. Occasionally the mass may 
give rise to a severe neuralgia, not confined to the ear alone, 
but spreading over the temporal and supra-orbital regions, 
and sometimes involving the entire trigeminal distribution. 



270 IMPACTED CERUMEN. 

Sometimes this affection of the sensory nerves produces a 
feeling not so much of pain as of numbness, involving the 
aural region or the entire side of the face. 

One of the most common reflex disturbances is cough. 
So common is this that examination of the ear is essential in 
the investigation of every case when complaint is made of 
this symptom alone. This cough is spasmodic in character, 
and from its severity may induce so much congestion of 
the larynx as to mislead the physician into believing that 
the laryngeal condition is the cause rather than the effect of 
the symptom. 

Not only is the auditory function perverted or impaired, 
but also the mental condition of the patient may be disturbed. 
The patient graduallv finds that he is unable to concentrate 
his thoughts upon any one particular subject, and that all 
mental processes are slow. The condition may become so 
marked as entirely to unfit him for any occupation requiring 
the exercise of his mental faculties. This disturbance is de- 
pendent entirely upon reflex action, and not upon the impair- 
ment of the hearing. Attention is particularly drawn to it 
from the fact that parents are often inclined to consider chil- 
dren inattentive when they are really suffering from a reflex 
disturbance dependent upon some pathological process within 
the ear. In these cases, unless attention is particularly directed 
to this organ by an impairment of hearing, serious errors are 
liable to occur. 

Under this same head we must remember that interfer- 
ence with the function of the ear of the opposite side may 
result from the presence of a foreign body within the meatus. 
While this phenomenon is rarely prominent, every one who 
has carefully tested the hearing in both ears, in cases where 
the canal of one side has been occluded by a foreign body, 
must have noticed that we seldom find the ear on the unaf- 
fected side normal, although the patient may be conscious 
of no impairment, and if questioned will usually reply that 
the other ear is perfectly sound. When we remember the in- 
fluence which a sounding body held before one ear has upon 
the sensitiveness of the organ of the opposite side, it is not 
strange that an occlusion of the external canal upon one side 
may seriously interfere with the hearing power of the oppo- 
site ear. 

So far we have considered simply reflex disturbances of a 



DIAGNOSIS. 271 

sensory nature ; many cases have been reported, however, in 
which epileptiform seizures have resulted from the presence 
either of impacted cerumen or of some other foreign body 
within the external auditory meatus, the attacks being entirely 
relieved upon its removal. Dizziness may occur from the 
direct pressure of the impacted cerumen upon the drum 
membrane, by which the attached ossicular chain is crowded 
inward, increasing labyrinthine pressure ; it may result also 
from reflex disturbances due to circulatory changes within 
the semicircular canals or the intracranial centres. 

When the impaction takes place in an ear which has pre- 
viously been the seat of purulent inflammation, in addition to 
the symptoms already described, serious consequences may 
result from the obstruction to the free outflow of discharge. 
This is particularly apt to occur in cases of chronic purulent 
otitis media of long duration, where the discharge is small in 
quantity as a rule, but may be suddenly increased in amount 
from exposure to cold or some other cause. In these cases, 
the scant discharge, mixed with the normal cerumen, dries in 
the canal and forms crusts, sometimes of almost stony hard- 
ness, which prevent the exit of any fluid which may be 
formed within the middle ear during an acute inflammation 
of the parts. It is possible here for the pent-up secretion to 
find entrance into the cranial cavity, and cause death by in- 
volving the intracranial structures. 

Diagnosis. — It is impossible to make a diagnosis upon 
rational symptoms alone, but objective examination at once 
reveals the condition. Upon inspecting the parts, occlusion 
of the canal is at once evident, and the determination of the 
exact nature of the mass before removal is of no importance. 
Attention, however, should be given to one point in the ex- 
amination of these cases : it is the presence on the postero- 
superior wall of the canal of a mass consisting apparently of 
cerumen, which extends along this aspect of the meatus in- 
ward over the drum membrane, entirely or partially covering 
it. This appearance is almost always indicative of a pre- 
ceding suppurative process within the tympanum, the foreign 
body being really inspissated secretion, mixed with a certain 
amount of normal cerumen. Before removing this, the patient 
should always be warned that the ear may discharge after 
the mass has been removed. The subsequent otorrhcea does 
not depend upon the removal of the mass, but upon a pre- 



272 



IMPACTED CERUMEN. 




viously existing intratympanic suppuration. If not warned 
beforehand the patient may scarcely understand this. Where 
the meatus is entirely occluded, and a view of the deeper 
parts is impossible, this condition may be present, and it is 

often wise for the surgeon to 
protect himself even here, al- 
though it is not of as great im- 
portance as when the mass oc- 
cupies the situation above de- 
scribed. 

Prognosis. — The presence of 
a mass of cerumen in the exter- 
nal auditory meatus does not of 
itself constitute a menace to life, 
nor does it prevent a complete 
restoration of the auditory func- 
tion after the removal of the for- 
eign body. The serious conse- 
quences which occasionally fol- 
low the presence of these masses 
is due to secondary pathologi- 
cal changes which they excite, 
either by causing hyperaemia and subsequently inflamma- 
tion, as the result of their pressure, or by setting up an in- 
flammatory process of desquamative type in the external 
auditory meatus, with a resultant absorption of the surround- 
ing bony walls or a perforation of the membrana tympani. 
When the affected ear is the seat of a chronic purulent otitis 
media, the presence of any foreign matter within the canal 
which may prevent the free discharge of pus from the middle 
ear renders the patient liable to all the serious consequences 
which may follow pus retention in any other part of the 
body. It seems curious that a mass of cerumen can offer 
sufficient resistance to pent-up secretions to cause them to 
seek an exit through the cells of the mastoid process, or to 
discharge into the cranial cavity, rather than to force their 
way past the obstruction in the external auditory meatus. 
The fact, however, remains that a mass of cerumen, lodged in 
the meatus for a considerable time, will obstruct this passage 
so completely that no discharge can escape. The osseous 
walls of the mastoid cells yield more easily to the pressure of 
pent-up secretions than does this mass of fatty matter. Again, 



Fig. 89. — Crust on supero-posterior 
wall, covering a perforation in 
the membrana tympani. (Natural 
size.) 



PROGNOSIS. 



273 



in these cases the mere presence of this collection within the 
meatus excites a certain amount of chronic inflammation of 
the epidermis lining the canal, this inflammation being usu- 
ally of the desquamative type. The slight amount of dis- 
charge from the tympanic cavity mixing with these desqua- 
mated epithelial cells forms a mass which is exceedingly firm, 
and which, increasing gradually in size, is capable of causing 
absorption of the osseous walls. The extent to which this 
may progress is unlimited, and even the cranial cavity may 
be invaded and a purulent infection of its contents may re- 
sult. In cases where the tympanic membrane remains intact, 
the pressure of the mass may force this structure inward 
against the bony tympanic wall, and by pressure cause an 
atrophy of the fibrous layer of the membrane. At the same 
time the desquamative inflammation excited by the plug of 
cerumen involves the superficial layer of the drum membrane 
as well as the canal walls. The epithelial cells which have 
been cast off may adhere so firmly to the atrophic membrana 
tympani that upon removal of the foreign body this delicate 
septum may be ruptured in spite of the greatest care. Even 
if the membrane is ruptured, complete restoration of func- 
tion may take place, although the accident adds a certain 
amount of gravity to the condition. It is always well, there- 
fore, for the surgeon to protect himself by giving a guarded 
prognosis in any case of ceruminous impaction in the canal, 
in which the mass seems to be of considerable firmness, and 
when there is evidence that it has existed for a long time. 
The effect upon the opposite ear should always be borne in 
mind, and a careful test of the hearing power upon both sides 
should be made before and after removal. If the accumula- 
tion is recent, complete restoration of the normal hearing 
power may be confidently expected. If, however, we have 
reason to believe that the canal has been obstructed for sev- 
eral years, it is probable that the hearing will not be perfect 
even after the foreign body has been removed. Moreover, 
since complete occlusion of the meatus makes it impossible 
for the observer to inspect the condition of the deeper parts, 
an absolute opinion should be given only after the obstruction 
has been thoroughly cleared away and the fundus of the canal 
exposed to view. 

These masses within the meatus exert considerable pres- 
sure upon the surrounding walls, and their sudden removal 
19 



274 IMPACTED CERUMEN. 

often causes a transitory hyperaemia of the parts, which par- 
ticularly predisposes to the development of a circumscribed 
inflammation, and the appearance of a furuncle following 
the operation is by no means of rare occurrence. In other 
instances, this sudden increase in blood pressure causes a 
rupture of the superficial vessels, developing a blood bleb 
upon the walls of the meatus, usually upon the inferior wall, 
close to the membrana. This may attain such a size as to 
obstruct the canal considerably, while its color so nearly re- 
sembles that of the ceruminous deposit as to be mistaken for 
it. The operator is liable to inflict considerable violence upon 
the patient before the mistake is discovered, unless he bears 
the possibility of this occurrence in mind. 

In one instance coming under the observation of the 
author this sudden removal of support to the blood vessels 
was followed by a serous transudation into the tympanum. The 
amount of fluid effused was so great as to cause intense pain 
from pressure upon the membrana tympani. A free incision 
through the membrana gave exit to the fluid, and was fol- 
lowed instantly by relief. 

Treatment. — The first indication in a case of this char- 
acter is to remove the mass, and it can not be too strongly 
insisted upon that when an effort to remove such an accumu- 
lation from the external auditory canal has been instituted, it 
should not be discontinued until the canal has been completely 
cleared. 

An exceedingly pernicious habit is practiced, not only by 
physicians without special training but by many otologists 
as well, of ordering these patients to instil a few drops of an 
alkaline solution into the ear at regular intervals for the pur- 
pose of softening the mass of cerumen, to render removal 
more easy at a subsequent period. As we know nothing of 
the conditions of the deeper parts, it seems strange that this 
method of procedure has ever been countenanced. The 
symptoms caused by the obstruction may be so indefinite 
that almost any condition may coexist, and to allow the 
patient to pass from observation without determining defi- 
nitely the presence of any coexisting pathological condition 
within the tympanum is certainly unwise. Another reason 
for condemning this plan lies in the fact that these masses 
may consist largely of dry epithelial cells, and the absorption 
of moisture will considerablv increase their volume. In this 



TREATMENT— SYRINGING. 



275 



manner great pressure will be exerted upon the walls of the 
meatus, causing intense suffering to the patient, and frequently 
leading to a circumscribed external otitis. 

The cardinal rule, therefore, should always be to remove 
the collection at the first sitting. The instrument which is 
best adapted for this purpose is the ordinary ear syringe (Fig. 
82). In a large majority of cases thoroughly syringing the ear 
will remove such a collection in a few moments. The solution 
to be used is a matter of considerable importance, for, as the 
condition of the deeper parts is unknown, the fluid should be 
of such a character that its entrance into the tympanic cavity, 
through the accidental rupture of the drum membrane or 
through a previously existing perforation, would be followed 
by no serious consequences. The syringe, therefore, must be 
perfectly aseptic, and the solution used should possess anti- 
septic properties. A solution of the bichloride of mercury — 
1 to 5,000 or 1 to 8,000 — is the one which I prefer. The fluid 
should be used at a lukewarm temperature, the sensations of 
the patient being the guide to the exact temperature to be 
employed. Since the removal of the obstruction in this man- 
ner depends upon the passage of a stream of water between 
it and the canal wall, and the gradual crowding outward of 
the mass by this current, the stream should be directed 
where the greatest space exists between the foreign body and 
the canal wall. Naturally, if the current impinges directly 
upon the centre of the obstruction, this will be driven inward 
rather than outward. If, on inspection, we find that the in- 
spissated secretion is firmly attached on all sides to the walls 
of the passage, it is frequently advisable to begin the process 
by removing a small portion of the mass close to the canal 
wall with a blunt curette, in order that the stream may be 
able to pass the obstruction. The force to be used in the 
procedure is best guided by the sensations of the patient ; the 
syringing should never be painful, although in certain in- 
stances the mere entrance of the stream of water will cause 
considerable dizziness. It is well to begin by using very little 
force, gradually increasing it as may be necessary. If we 
were certain that the drum membrane were in its normal con- 
dition it would be almost impossible to rupture it by the use 
of the ordinary ear syringe. As it may be atrophic, however, 
care should be taken that no undue violence is employed in 
our efforts at removal. Where inspection reveals the canal 



276 



IMPACTED CERUMEN. 



completely stopped by the mass, and the use of the curette in 
the manner already described seems inadvisable, the plan 
usually followed is to direct the syringe so that the stream of 
water will impinge first upon the superior wall of the canal, 
next the posterior, then the inferior, and last upon the ante- 
rior wall. If the circumference of the canal is followed in this 
order, the instances will be rare in which the plug will not 
be rapidly displaced, the water at some particular point gain- 
ing entrance between the wall and the obstructing body, and 
rapidly forcing it outward with each successive discharge of 
the syringe. We occasionally meet with cases which resist 
all efforts at removal in this manner ; in such an event the 
blunt curette must be used, and the collection removed piece- 
meal. Here it should be borne in mind that the upper and 
posterior portion of the drum membrane is nearer the opera- 
tor than the lower and anterior portion ; it is unsafe, there- 
fore, to undermine the deposit by following the anterior wall 
of the canal and then attempt its removal by crowding the 
curette upward against the remaining portion, endeavoring 
to displace it by traction outward. If the drum membrane is 
sunken, pressure will be brought directly against this struc- 
ture and much suffering will certainly follow, and in many 
instances it will be ruptured. It is wiser, therefore, to follow 

the posterior wall of the 
canal inward, effecting 
removal of the mass by 
pressing the curette down- 
ward and forward toward 
the anterior wall, at the 
same time employing trac- 
tion outward, removing 
in this way so much of the 
mass as lies between the 
curette and the opposite 
canal wall. After the 
drum membrane has been 
once brought into view, 
the remaining fragments 
may be displaced either 
by the syringe or by the use of the curette, following any 
particular manipulation that may seem adapted to the de- 
mands of the individual case ; but until this structure is seen, 




Fig. 90. — Method of removing cerumen with 
the curette. (Natural size.) 



TREATMENT— USE OF THE CURETTE. 



277 



the plan above laid down is the one which should be fol- 
lowed. Where the canal is exceedingly sensitive we may 
vary the manipulation by removing the central portions of 
the mass first, a thin layer of cerumen being left on all sides 
closely adherent to the walls of the meatus ; this tubular rem- 
nant is then broken down by introducing the curette into 
the channel thus prepared, when, by pressing the instrument 
toward the wall of the meatus, the included fragment may be 
extracted. If the operator should be so unfortunate as to 
rupture the membrana tympani, the first care should be thor- 
oughly to cleanse the entire field by means of an antiseptic 
solution, and thus reduce to a minimum the chances of in- 
fection of the tympanum. 

A rather curious condition which was observed in one 
of my cases was the sudden effusion of a large quantity 
of serum into the middle ear following the removal of a 
mass of impacted cerumen which had lain in the canal for 
many years. The only explanation that could be offered in 
this case was that the blood vessels of the tympanum had 
been so compressed by the accumulation within the canal 
that they had lost their tone. The removal of the mass sub- 
jected them quite suddenly to the pressure of the blood cur- 
rent, and resulted in a rapid transudation of the fluid elements 
of the blood ; in this case a minute rupture of the atrophic 
drum membrane occurred. A few hours after the operation 
the patient was suffering intense pain ; the middle ear was 
full of a sero-sanguinolent fluid, which passed out as rapidly 
as possible into the canal through the small perforation which 
had been made. Feeling confident that no inflammatory con- 
dition could be present in so short a time, as strict antiseptic 
precautions had been taken throughout the entire procedure, 
the pain was attributed simply to the pressure of the fluid 
within the tympanum. A long incision close to the posterior 
attachment of the membrana tympani to the tympanic ring 
evacuated the fluid, the knife dividing the mucous membrane 
upon the internal tympanic wall at the same time that the 
section of the drum membrane was effected. Relief was im- 
mediate, and in thirty-six hours the opening had closed com- 
pletely, the patient regaining perfect hearing at the end of 
ten days. 

After a large mass of cerumen has been removed, it is 
well to insert a pledget of cotton into the meatus, directing 



278 IMPACTED CERUMEN. 

the patient to remove it upon retiring for the night, after 
which it need not be replaced. Since these masses ordinarily 
contain a certain number of parasitic vegetable organisms, 
the patient should be seen once or twice subsequently to 
guard against the development of these parasitic growths. 
It is advisable during the interval between the visits that an 
alcoholic solution either of boracic acid, in the proportion 
of forty grains to the ounce, or of salicylic acid, ten grains to 
the ounce, should be instilled into the canal twice daily; this 
will effectually destroy any vegetable spores which may re- 
main, and render a reaccumulation less liable to occur. This 
plan of treatment is also indicated, since, in removing the 
mass, it is not unusual that small areas may be abraded and 
render the occurrence of an acute circumscribed external 
otitis probable. No case should be considered thoroughly 
cured until the entire cutaneous lining of the meatus is per- 
fectly normal. 



CHAPTER XIV. 

FOREIGN BODIES IN THE CANAL. 

iEtiology. — We have already described, under Impacted 
Cerumen, the various symptoms which may arise from the 
presence of any foreign substance within the external audi- 
tory canal, but here the presence of the foreign body in the 
canal is due to natural causes. The symptoms occasioned by 
a foreign body in the external auditory canal, which has 
either developed there spontaneously or has obtained lodg- 
ment there by accident or design, are exactly similar. We 
shall therefore omit a repetition of the symptomatology, and 
confine ourselves to the consideration of the nature of the 
substances which are met with in this locality, and the meas- 
ures which may be necessary to effect their removal. 

Pathology. — These foreign substances may be divided 
into two great classes : the inorganic and organic. The inor- 
ganic substances which have been removed from the external 
meatus are almost infinite in number. Children seem to take 
special delight in introducing into the meatus any article 
which can be made to enter it. Thus we frequently find 
buttons, glass beads, pebbles, sand, broken glass — in fact, 
anything which chance may throw in their way — introduced 
into this passage. A pernicious habit, frequently adopted, 
is the introduction of cotton into the ears of a child when 
it is taken out of doors on a cold day ; the mother often 
neglects to remove this, and the child may subsequently 
crowd it deeply into the meatus in its efforts to dislodge it. 
In this situation it may remain, often for many years, and it is 
not uncommon in dispensary practice to find a small plug of 
cotton forming the nucleus of a mass of impacted cerumen, 
the patient being unable to state when the foreign substance 
was introduced. 

Among the organic substances found are apple seeds, 
watermelon seeds> cherry pits, the shells of edible nuts, small 

(279) 



28o FOREIGN BODIES IN THE CANAL. 

pieces of straw which have been used by the patient to 
scratch the ear, or minute splinters of wood which may have 
been broken off in the canal during a similar effort on the 
part of the patient. Occasionally the body of a dead insect 
is found, the insect having gained entrance to the meatus 
accidentally, and, being unable to escape, has remained there 
until removed by artificial measures. A living insect usually 
causes such marked symptoms by its presence in the canal 
that immediate efforts are instituted for its removal. When 
leeches are carelessly applied to the region of the ear — the 
meatus being allowed to remain open during the operation — 
the animal may detach itself from the point of application, 
and, making its way into the meatus, may attach itself to the 
drum membrane and cause intense suffering. Sometimes the 
eggs of the common house-fly are deposited in the canal and 
subsequently become developed into living insects, constitu- 
ting a condition distressing to the patient and disgusting to 
the observer. 

Symptomatology. — Very little need be said about the 
symptoms produced by a foreign body, as we have already 
discussed the subject thoroughly under Impacted Cerumen. 

That a foreign substance may lie in the meatus for a num- 
ber of years without giving rise to any symptoms, and then 
suddenly make its presence felt by manifestations of unusual 
severity at first, appears strange ; yet this is easily under- 
stood, if we consider that an irregularly shaped body may, 
in this locality, exert no pressure on the surrounding walls, 
but if suddenly displaced ever so little may impinge upon 
delicate and sensitive parts. Any foreign substance which 
increases in volume by the absorption of moisture is particu- 
larly liable to produce symptoms of increasing severity. 
Beans or seeds which when dry may be easily dropped into 
the canal become moistened by perspiration, and attain such 
a size that their spontaneous exit becomes impossible. While 
this increase in volume may not be sufficient to constitute a 
source of discomfort, the introduction of water into the 
meatus while bathing may bring about this result. Again, 
if there is at the same time a suppurative otitis media, the 
discharge from the tympanum will cause a foreign body to 
increase in volume. The local irritation which a foreign 
body exerts upon the walls of the canal increases the secre- 
tion from the cutaneous lining, the superficial epithelium is 



DIAGNOSIS— PROGNOSIS. 28 1 

thrown off rapidly, and the canal is filled with these white, 
moist scales. This condition is particularly favorable for the 
development of the various forms of parasitic growths, or of 
a local infectious process ending in a circumscribed or diffuse 
inflammation of the walls. Naturally all of these manifesta- 
tions are more common among the classes who pay little 
attention to personal cleanliness, or are exposed to surround- 
ings which render local infection especially easy. 

When the middle ear is the seat of suppuration, the for- 
eign body may interfere with proper drainage, and then 
symptoms of pus retention ensue. 

Diagnosis. — The recognition of any foreign substance 
lying within a perfectly patulous canal is exceedingly sim- 
ple. Unfortunately, however, these patients are seldom seen 
immediately after the introduction of the foreign body and 
before efforts have been made to effect its removal. These 
attempts at the hands of the patient are necessarily unskillful, 
and result in the infliction of considerable injury to the sur- 
rounding parts. If the case is inspected at the end of a few 
days, the canal may be so swollen that the deeper parts are 
entirely invisible, the softer tissues prolapsing about the for- 
eign body and completely hiding it ; while at the same time 
the secretion from the parts, the desquamated epithelium, 
and the presence of dried blood which has followed the efforts 
at removal, so distort the normal appearance that an exact 
diagnosis is a matter of great difficulty. The parts may be 
so tender that only the smallest speculum can be introduced, 
while manipulation may be impossible. Under these condi- 
tions, our diagnosis must depend entirely upon the history ; 
when this clearly indicates the nature of the affection with 
which we have to deal, it is unwise to prolong the examina- 
tion, as the indications for treatment are identical, no matter 
what the nature of the substance may be. 

Prognosis. — The outcome of the condition will depend 
more upon the local disturbance which is present than upon 
the nature of the foreign body or its location. The parts in 
some cases are exceedingly tolerant, while in others compara- 
tively harmless substances may give rise to severe symptoms. 
Probably nothing increases the gravity of a case to such an 
extent as unsuccessful attempts at removal, the body itself 
doing less harm than unskillful efforts in this direction. 

When the condition has existed for a considerable period, 



282 FOREIGN BODIES IN THE CANAL. 

the presence of profuse purulent discharge will indicate that 
the tympanum has been invaded, while involvement of the 
mastoid cells or interference with the outflow of pus will be 
evidenced by characteristic signs. 

Treatment. — The instrument which should be employed 
for the relief of this condition is the ear syringe. It is prob- 
ably safe to say that our first efforts should always be to clear 
the canal, if possible, by this means alone. Although it may 
seem perfectly simple to remove the foreign body with the 
forceps, with hooks, or similar instruments, attempts to grasp 
hard, smooth objects usually result in crowding them deeper 
into the canal, where they become impacted and are removed 
with great difficulty. A stream of water thrown with con- 
siderable force into the meatus is usually sufficient to dislodge 
any obstruction, while it inflicts no violence upon the parts. 
The only instance in which it may be wise to attempt re- 
moval by manipulation is in the case of seeds or dried vege- 
table substances, which may increase in volume so rapidly 
when moistened as to fill the canal completely. If a sharp 
hook can be made to penetrate such a foreign body to a con- 
siderable depth, this is usually the simplest measure for its 
removal. Forceps should only be used where the body is 
thin and flat, and may be grasped easily in the jaws. When 
the contour of the body is more or less spherical, the efforts 
to grasp it will usually result in the instrument slipping and 
actually crowding the obstruction toward the fundus of the 
canal. Continued efforts in this direction may often force the 
object against the tympanic membrane, and even into the mid- 
dle ear. It is sometimes possible to introduce a blunt curette 
between the object and the canal wall until the instrument 
has passed the obstruction ; the instrument is then withdrawn, 
and the foreign body removed with it. It may be necessary, 
in the case of small, soft objects, to disintegrate them in the 
canal by instruments, and remove them piecemeal. This is 
particularly true of seeds, the shell being broken, and the 
soft interior removed by the curette, after which the remain- 
der of the shell can be easily taken away. 

The necessity of anaesthesia must be determined in each 
individual case. It is an error, however, to prolong the 
efforts at removal where the patient is extremely nervous, on 
account of the damage which may be done to the surround- 
ing parts ; and, unless they meet with prompt success, the 



TREATMENT— EXTERNAL OPERATION. 



283 



patient should be thoroughly anaesthetized before continuing 
the operation. In some rare instances, where the condition 
has been neglected, the meatus may become so small that it 
is impossible to extract the foreign body through the natural 
passage. Under these circumstances a more radical proce- 
dure becomes necessary. 

The patient being thoroughly anaesthetized, the parts 
above and behind the ear are shaved, thoroughly scrubbed 
with soap and water, washed with a five-per-cent carbolic 
solution and subsequently with ether, the external meatus 
having been previously syringed with a two-per-cent carbolic 
solution or some other antiseptic fluid, and tamponed with 
iodoform gauze. An incision is then made from just below 
the insertion of the lobule, upward along the line of attach- 
ment of the auricle to a point just above the meatus, and then 
forward as far as the helix ; the fibrocartilaginous canal is 
then loosened from its attachment by means of the periosteum 
elevator, the instrument being applied first below and then 
behind, the superior wall being detached last. In the same 
way the periosteum of the canal is separated from the bone, 
and the fibro-'cartilaginous tube is divided transversely as near 
the drum membrane as possible. 

This anterior flap, consisting of the auricle and the soft 
parts of the meatus, is turned forward, and entrance is thus 
gained to the bony meatus directly, and the path to the for- 
eign body is shortened by the length of the cartilaginous canal. 
This amount of gain is inconsiderable when we remember that 
the parts are covered with blood, and the view to a degree ob- 
structed by the haemorrhage. If the fibrous canal is swollen, 
as the result of secondary inflammation, and this is the only 
obstacle to the removal of the foreign body, we may be able 
to extract it at once after the flap has been turned forward. 
In case the object is found so firmly fixed in the canal that 
efforts at extraction are still futile, the lumen of the meatus 
can be enlarged with a chisel by carefully chipping away 
the bone from the posterior wall until sufficient space is ob- 
tained to remove the object. It is better to enlarge the pas- 
sage by the removal of a portion of the osseous wall than 
to attempt to extract the body by forcible manipulation. The 
operation presents no difficulties, and we should never delay 
in adopting this plan whenever extraction through the natural 
passage seems impossible. If, in our efforts, the tympanic 



284 FOREIGN BODIES IN THE CANAL. 

cavity has been unavoidably opened, this feature does not 
add to the gravity of the condition. The parts should be 
thoroughly cleansed, and the wound in the tympanic mem- 
brane will soon close, and, as a rule, the middle ear suffers 
very little from the accident. After the purpose for which the 
operation has been undertaken is accomplished, the soft parts 
should be replaced, and the line of incision sutured by a con- 
tinuous subcutaneous catgut suture ; a rubber tube should 
be inserted into the meatus, both for the purpose of drainage 
and to keep the parts in position. Sufficient drainage is se- 
cured in this way, and primary union throughout the entire 
length of the incision should be looked for. If there is but 
little inflammatory change in the tissues of the meatus as the 
result of the presence of the foreign body, a light tampon of 
iodoform gauze may be inserted instead of the drainage tube. 
This should extend to the fundus of the meatus to secure 
proper drainage, and will be found to support the walls of 
the canal sufficiently. Unless the temperature indicates the 
necessity for doing otherwise, the dressing may remain un- 
touched for six days, when the parts will have united com- 
pletely. If there has been much previous laceration of the 
soft parts, it is usually wise to change the dressing at the end 
of the second or third day. If much discharge is found at 
this time the canal should be irrigated ; but if the parts are 
dry this is not necessary. The tube may be removed at the 
first dressing and the tampon of gauze substituted. The only 
unpleasant sequel which can result from the operation is the 
possible narrowing of the canal from cicatricial contraction, 
and this can be avoided if the parts are properly apposed 
after the operation and held in position for twenty-four or 
forty-eight hours. 



CHAPTER XV. 

EXOSTOSES OF THE EXTERNAL AUDITORY MEATUS. 

^Etiology. — The development of a new growth of an osse- 
ous character in the external canal has been attributed to 
various causes. It was formerly supposed that a gouty or 
rheumatic diathesis predisposed to the condition, although 
statistics fail to bear out this view ; and the same may be said 
of specific disease. 

Persistent irritation of the external auditory canal, espe- 
cially by the presence of a purulent secretion such as occurs 
in individuals suffering from neglected purulent otitis media, 
seems to be the most common certain cause for the develop- 
ment of these bony growths. Race also exerts a decided 
influence, the growths being more commonly met with among 
Europeans than among the inhabitants of our country, al- 
though among the aborigines they were of frequent occur- 
rence, as is proved by an examination of skulls discovered 
through archaeological research. The natives of the Ha- 
waiian Islands also manifest the condition quite commonly, 
and from their aquatic habits this fact lends great weight to 
the argument that the irritating action of salt water exerts a 
most important influence in the formation of these osseous 
growths. 

Their occasional occurrence in successive generations in 
the same family seems to point to a certain hereditary predis- 
position, although this is far from proved. 

Pathology. — The portion of the canal in which these 
growths are most frequently found is either the junction of 
the cartilaginous and bony meatus or the deeper portion of 
the osseous channel. They occur in two forms, either as dis- 
tinct pedunculated masses, or as protuberances from the bony 
wall arising by a broad base. In structure they may be either 
cancellous or hard as ivory. A single bony mass may be 
present, or, as more frequently happens, they are multiple, 
projecting into the lumen of the canal from various aspects. 

(285) 



286 EXOSTOSES OF THE EXTERNAL AUDITORY MEATUS. 

Where the canal is obstructed by multiple growths, it 
preserves its circular form in a modified degree, the space 
left between the obstructing masses lying in the axis of the 
meatus. Where a single excrescence of large size is the cause 
of occlusion, the meatus is converted into a slitlike passage 
by the approximation of the growth to the opposite wall. 

Symptomatology. — A small bony tumor in the external 
canal gives rise to no subjective evidence of its presence, and 
even where the deposit is multiple the condition may be dis- 
covered only by accident. When they attain a sufficient size 
to obstruct the passage to a considerable degree, the func- 
tion of audition is interfered with. Certain other subjec- 
tive symptoms now make their appearance : the ear feels 
full and stopped up, there is autophonia, and quite commonly 
subjective noises. The normal secretion from the walls of 
the meatus may collect beyond the tumor, and, being unable 
to find exit on account of its presence, becomes impacted, 
and exerts a steadily increasing pressure upon the membrana 
tympani and the walls of the bony meatus. This pressure 
tends to increase the condition from the mechanical irritation 
which it causes. If the accumulation is not removed arti- 
ficially, the pressure may excite an acute inflammation within 
the middle ear, or an acute external otitis. This is especially 
prone to occur if water is introduced into the meatus, causing 
the mass to suddenly increase in volume. On the other hand, 
an acute inflammation of the middle ear, arising from another 
cause, may lead to serious results on account of the obstruc- 
tion to the exit of the fluid products of the inflammation. For 
this last reason exostoses of large size become a menace to 
life, and when once discovered the patient should be cau- 
tioned to submit to an examination periodically at the hands 
of an expert, in order that no extensive accumulation of ceru- 
men shall take place beyond the obstruction and cause com- 
plete occlusion. 

The degree to which these masses interfere with hearing 
varies considerably. Even when the meatus is exceedingly 
narrow the power of audition may not be noticeably impaired 
in the ordinary intercourse of life. 

Diagnosis. — Otoscopic examination usually renders the 
diagnosis clear at once. Where the growth is pedunculated, 
bulging, and broad, and especially if the surface is covered 
by a thin layer of cerumen, the examiner may at first be mis- 



DIAGNOSIS— PROGNOSIS. 



287 



led as to the character of the obstruction, the appearance pre- 
sented in these cases being quite similar to epithelial debris 
mixed with cerumen closely applied to the wall of the meatus. 
Manipulation by means of the curette at once reveals the true 
character of the formation. Upon removal of the layer of 
dried secretion upon the surface by means of the curette, the 
integument is frequently found to be eroded and excessively 
tender to the touch. Undoubtedly the efforts of the patient 
to remove these crusts when the growth is near the orifice of 
the canal accounts for the steady growth in many instances. 
Located close to the drum membrane, and presenting as one 
or more small rounded protuberances, these bony excrescences 
may resemble closely a localized bulging in Shrapnel's mem- 
brane, but here again the probe reveals the true condition. 

The clinical history, and the resistance offered to the im- 
pact of the probe, discloses the true nature of the mass. The 
same points distinguish it from a circumscribed external otitis, 
or, where the neoplasm arises from a broad base, from a symp- 
tomatic diffuse otitis externa. 

Prognosis. — These neoplasms follow a different course in 
different cases. The progress followed by any individual 
growth is probably more dependent upon the causes opera- 
tive in its production than upon any other condition. Thus, 
if it is secondary to a purulent inflammation of the middle 
ear, the mass will undoubtedly increase in size until the irri- 
tating discharge has been controlled. Those cases depending 
upon diathetic conditions alone undoubtedly advance less rap- 
idly, and here the increase in size is seldom sufficient to de- 
mand operative treatment unless an intercurrent acute inflam- 
mation of the tympanum takes place, necessitating the removal 
of the exostosis to secure proper drainage. After removal 
the growth does not tend to reappear. We are seldom able 
to restore, however, the normal lumen of the meatus, even 
though the tumor is completely taken away. The local irri- 
tation which must necessarily follow the operation excites a 
certain amount of inflammation in the bony tissue which leads 
to hypertrophy of the wall of the bony canal, and consequent 
narrowing of its lumen. 

The possibility of an exostosis degenerating into a malig- 
nant neoplasm should be borne in mind, especially when it is 
situated near the orifice of the meatus and constitutes a source 
of local discomfort. Under these conditions the patient con- 



288 EXOSTOSES OF THE EXTERNAL AUDITORY MEATUS. 

tinually irritates the canal in this region by the introduction 
of the finger or some blunt instrument to relieve the pruritus 
— a process which serves to keep the integument over the 
bony growth denuded of its superficial epithelium. From 
this constant local irritation a benign osseous tumor may as- 
sume the form of an osteo-sarcoma. These remarks would 
scarcely apply to growths located in the deep canal. 

Regarding the function of the organ, the remarks already 
made concerning the increase in the size of the tumor may 
be taken as an index of its probable effect in this direction. 
Lesions of this character endanger life only when they act as 
an obstruction to free drainage from the more deeply situated 
parts when these are the seat of an inflammatory process. 

Treatment.— Where the exostosis is deeply located, of 
small size, and gives rise to no symptoms, operative treatment 
is unwarrantable. It is well, however, to keep the patient 
under observation, the ear being examined at long intervals 
to ascertain whether the growth is progressive or has ceased 
to increase in size. It is surprising how narrow the meatus 
may become and yet impair in no degree the function of 
audition. 

When multiple growths are present, if the hearing is not 
noticeably impaired, interference is scarcely called for, al- 
though the patient should be advised to submit to an occa- 
sional examination in order that any secretion which may 
have collected may be removed before it has become im- 
pacted so firmly- as to prevent its dislodgment without great 
difficulty. Sea bathing should be interdicted, on account of 
the irritating effect of the salt water, and at the same time the 
patient should be cautioned against allowing fluid of any sort 
to enter the meatus, since by this means any collection of 
cerumen or of desquamated epithelial cells may become so 
augmented in volume as to excite severe pressure symptoms. 

Where the obstruction of the meatus is almost complete, 
so as to interfere with the function of audition, or where the 
slightest increase in size would entirely close the canal, it is 
our duty to remove the exostosis. The precise manner in 
which this is to be done will vary according to its location, 
its form, and the individual preference of the operator. 
When the growth springs from a narrow base, and is situ- 
ated near the entrance of the bony canal, it is usually an 
easy matter to separate it by a chisel introduced into the 



TREATMENT. 



289 



meatus, and if carefully conducted the procedure does not 
endanger the parts within the tympanum. When more than 
one growth is present, or when the condition occurs close 
to the drum membrane, or springs from an extensive attach- 
ment, this simple measure is not efficacious, as we have no 
means of protecting the deeper structures. Moreover, those 
growths, springing from a broad base, are usually of an 
ivorylike hardness, and are but little affected by chisels 
small enough to be introduced into the canal, the instrument 
frequently glancing from the surface of the tumor and inflict- 
ing serious injury upon the parts beyond. The surgical en- 
gine may be used in these cases, the base of the growth being 
perforated by means of fine drills, thus weakening its attach- 
ment to the wall of the meatus and permitting its removal 
with cutting instruments, or the entire obstruction may be 
cut away with a properly constructed burr. Where one is 
familiar with the manipulation of the dental engine, the oper- 
ation, if carried out in this manner, can be performed with 
greater safety than by any other method. 

Where the growth is so large as to render it impossible to 
discover the exact site of its attachment it is well to expose 
the orifice of the .bony canal by an incision behind the auricle, 
and to displace the auricle forward so as to gain better access 
to the bony meatus. The operative technique is the same as 
that already detailed for the removal of foreign bodies. After 
this has been done, either the chisel, the drill, or the burr may 
be used, according to the preference of the operator. 

Where the growth is located upon the posterior wall it 
should be remembered that, although the tumor may be 
eburnated, the tissue of the mastoid itself is comparatively 
soft, and if the chisel is employed to remove the growth it is 
much simpler to remove a thin lamella from the mastoid, to- 
gether with the tumor, than to attempt to chisel through the 
base of the growth. Less traumatism is inflicted upon the 
surrounding parts by this procedure, and the ultimate result 
is correspondingly more satisfactory. 

Where a purulent otitis media of long duration is present, 
exostoses of moderate size should be removed on account of 
the probability of a steady growth with the consequent ob- 
struction to free drainage. In such cases it would be much 
better to detach the auricle than to attempt to operate 
through the canal. If this is done, we may at the same time 



290 EXOSTOSES OF THE EXTERNAL AUDITORY MEATUS. 

remove all carious bone from the tympanum, and effect a cure 
of the purulent otitis. 

Concerning internal medication but little can be said. 
Anti-rheumatic remedies exert practically no influence upon 
the progress of the local condition, and it is only where a dis- 
tinct specific history can be elicited that we have any reason 
to hope for improvement following the administration of in- 
ternal remedies. If the osseous mass within the meatus is 
considered to be of syphilitic origin, the administration of 
large doses of iodide of potassium should be tried before re- 
sorting to operative procedures. Even in these most favor- 
able cases the results are often disappointing. 



CHAPTER XVI. 

WOUNDS AND INJURIES OF THE MEMBRANA TYMPANI. 

JEtiology. — The partition separating the middle ear from 
the external portion of the conducting mechanism may suffer 
injury either by direct violence from instruments introduced 
into the meatus, or its continuity may be destroyed by indi- 
rect violence, by the sudden condensation of the air within 
the meatus, as when a heavy gun is fired close to the ear, 
or when one is in the vicinity of a heavy explosion. From 
the anatomical structure of the drum membrane, we remem- 
ber that its superior portion is directly continuous with the 
integument of the superior wall of the meatus. Traction 
upon the auricle, therefore, especially in children, may pro- 
duce a rent in this portion of the membrana. Irritating sub- 
stances introduced into the canal for the relief of pain in 
the ear, or for toothache, may produce a superficial inflam- 
mation of the lining membrane of the canal and of the drum 
membrane ; in the same manner a vegetable parasite grow- 
ing within the meatus causes a diffuse external otitis. When 
moderate in degree, such an inflammation amounts to nothing 
more than a dermatitis, the superficial epithelium being exfo- 
liated and the deeper layers exposed. When the inflamma- 
tion is of greater intensity actual tissue necrosis takes place, 
and the drum membrane may be perforated, thus exposing 
the tympanic cavity not only to infection from the air, but 
also to the direct action of the substance which has excited 
the inflammation within the canal and has caused the perfora- 
tion in the membrana tympani. As a result of this we have 
inflammation of the middle ear grafted upon the already ex- 
isting inflammation of the external meatus. Perforation of 
the membrane from inflammation within the tympanic cavity 
is of secondary importance to the original disease, and pre- 
sents no characteristic features. 

Pathology. — From the introduction of instruments into 

the canal injury to the membrana tympani is usually effected 

(291) 



292 WOUNDS AND INJURIES OF THE MEMBRANA TYMPANI. 

in the upper and posterior quadrant, since this region is most 
accessible, the angle formed between the cartilaginous and 
bony canal protecting the anterior portion of the membrane 
from injury. When the rupture follows a sudden condensa- 
tion of air in the meatus, either from a blow upon the ear 
or from an explosion, the rent is most frequently situated in 
the postero-superior quadrant, from the fact that the greatest 
breadth of the tympanic cavity lies in this region. Owing to 
some irregularity in the position of the structure an accident 
of this character may produce a rupture in the anterior por- 
tion of the membrane. Following traction upon the auricle 
the upper part is most frequently torn, and here the rupture 
is usually confined to the region of Shrapnell's membrane, the 
membrana vibrans being to an extent protected by its loose 
attachment to the membrana flaccida. Openings into the tym- 
panic cavity are usually single when of traumatic origin, but 
occasionally multiple perforations are found. They vary in 
shape from a simple rent, the edges of which are only slightly 
separated, to an irregularly circular opening, as occurs when 
the force is considerable, or when the membrane is very tense. 
If the septum is tightly stretched the elasticity of the struc- 
ture separates the edges of the tear, giving the appearance of 
a certain loss of substance. 

Following the introduction of chemical irritants, the de- 
struction depends upon the activity of the chemical agent in- 
stilled. 

We have purposely omitted the cases of rupture follow- 
ing severe injuries of the cranium, since here the aural affec- 
tion is of but slight importance in comparison with the frac- 
ture of the base of the skull or the cerebral concussion. The 
drum membrane in these cases may be injured either by a 
blow upon the side of the head, which suddenly compresses 
the air within the canal, or by a blow upon the skull which, 
by the force of impact, subjects the bony ring to great pres- 
sure at one point, and causes it to yield slightly, rupturing 
the attached membrane. 

Where the middle ear becomes secondarily involved, the 
pathology does not differ from that of a middle-ear inflamma- 
tion from any other cause except in the fact that it is usually 
purulent. 

Symptomatology. — When the drum membrane has been 
torn, the first symptom is severe pain, referred to the deeper 



SYMPTOMATOLOGY— DIAGNOSIS. 



293 



part of the organ. Coincident with this there is a very de- 
cided impairment in hearing and the development of loud 
subjective noises. Vertigo ordinarily occurs following a blow 
upon the ear, but this is due rather to a sudden increase in 
labyrinthine tension than to rupture of the membrana tym- 
pani. Very soon the patient is conscious of a watery dis- 
charge within the meatus, and the acute pain which was pres- 
ent immediately after the injury becomes dull, throbbing, and 
more diffuse. Upon blowing the nose the attention is at once 
attracted by the passage of the air through the ear, with the 
production of a high-pitched whistling sound. If secretion is 
present the high-pitched note is followed by bubbling sounds 
as the air passes through the fluid. Where the rent is large, 
the pain is usually of shorter duration than when but a small 
opening is present. The reason of this is that the copious 
serous transudation which immediately follows the injury 
finds a ready means of exit from the tympanic cavity, and 
produces less pressure upon the parts than where but a small 
opening exists. 

The subsequent progress of the case will vary according 
as the middle ear is or is not involved. In the first instance 
a rather long-continued suppurative process not infrequently 
follows, while, if the tympanum escapes, the rent of its outer 
wall may close perfectly in a few days, leaving no symptoms 
behind. 

Diagnosis. — A recent rupture is easily made out on exami- 
nation, its irregular contour being marked by a delicate line 
where the rupture is linear (Fig. 91), or by an 
apparent loss of substance over the affected 
region where a circular opening is present. 
Through this opening the mucous lining of the 
middle ear appears red and congested, throw- 
ing a bright reflex back to the eye from the 
moisture upon the inner tympanic wall. The „ 

r . r t FlG * 9 1 -— Linear 

history of traumatism in the region of the ear, rupture of the 
or of any injury to the skull, followed by an j^ brana tym " 
aural discharge, should lead to a careful ex- 
amination for any evidence of injury to the drum membrane. 
Where the rent occurs close to the margin of the ring it may 
escape recognition, unless the entire line of attachment of the 
membrane be inspected. Wounds in Shrapnell's membrane 
are less easily recognized than those in membrana vibrans, 




294 WOUNDS AND INJURIES OF THE MEMBRANA TYMPANI. 

owing- to the natural flaccidity of this part. Evidences of a 
previous rupture are the presence upon the surface of the 
drum membrane of minute blood clots, corresponding- in 
position to the outline of the rent, and the coexistence of 
delicate radiating vessels along this line which impart a slight 
pinkish tinge to the affected area. These vessels become visi- 
ble, owing to the increased vascularity incident to the repara- 
tive process. The presence of minute blood clots in the 
meatus also points to a previous injury. These appearances 
are of practical value only in medico-legal cases, where we 
may be called upon to determine the effect on the ear of a 
previous injury. 

Prognosis. — An opening made into the tympanic cavity 
as a surgical procedure is one of the simplest operative meas- 
ures employed. It is quite different, however, if the open- 
ing occurs as the result of an accident, when the meatus may 
contain an abundance of infectious material, which thus gains 
access to the mucous lining of the tympanum ; here it is 
easily absorbed and produces characteristic results. 

On account of this, an accidental rupture of the mem- 
brana tympani at the hands of the surgeon in attempting to 
remove a foreign body, either with the syringe or curette, is 
seldom followed by untoward results ; while the same acci- 
dent inflicted at the hand of the patient might lead to fatal 
consequences. In the one case, if proper precautions have 
been taken, the parts are in a thoroughly aseptic condition 
before the traumatism has occurred, and hence no infection 
follows, while the reverse is true in the latter instance. 

In general, the prognosis both for the ultimate closure of 
the opening and the restoration of the power of audition is 
fairly good, if the case comes under observation before a 
chronic purulent inflammation has supervened. If this has 
occurred, the result will depend upon the condition of the 
parts as revealed by the examination, independent of the 
cause which has produced it. 

Treatment. — As the surgeon, no matter how expert, will 
occasionally wound the membrana tympani, no instrument 
should be inserted into the meatus before this channel has 
been thoroughly cleansed. Even in removing foreign bodies 
by means of the syringe, the solution employed should be 
antiseptic in character, in view-of the fact that the tympanum 
may be accidentally entered. Under these conditions it is 



TREATMENT. 



295 



only necessary to dry the parts lightly with cotton, dust a 
little boric acid along the margins of the wound, and occlude 
the meatus with a pledget of sterilized cotton. A little se- 
rous discharge may follow, in which case the patient is direct- 
ed to change the cotton as frequently as it becomes saturated. 
No other treatment is necessary, the parts resuming their 
normal condition in from twelve to twenty-four hours, even 
when very free serous discharge has supervened. 

When seen at a later period, or in cases where it is prob- 
able that infection has taken place, local bloodletting from 
the region in front of the tragus may abort the inflammation. 
If the opening through the drum membrane is exceedingly 
minute, and the middle ear contains a large amount of fluid, 
the wisest plan is to make a free incision through the drum 
membrane, at the same time incising the opposite internal 
wall of the tympanum. This evacuates the contents of the 
cavity and depletes the vessels upon its inner wall. The 
measure is followed almost invariably by a prompt disap- 
pearance of the symptoms, the wound closing in from twenty- 
four to forty-eight hours. We sometimes meet with cases in 
which Nature has already sealed the opening by the deposit 
of a small blood clot upon the external surface of the drum 
membrane. No attempt should be made to remove this un- 
less there is severe pain, as healing invariably takes place if 
the clot is allowed to remain. Interference with it may pos- 
sibly infect the cavity and be followed by severe inflammation 
of the middle ear. Acute or chronic otitis media following 
the accident calls for the treatment indicated under the dis- 
cussion of these diseases. 



///. DISEASES OF THE MIDDLE EAR. 

The entire middle ear, from the pharyngeal orifice of the 
Eustachian tube to the inner surface of the membrana tym- 
pani, is covered with mucous membrane; this is supplied with 
glandular structures, in some parts very richly, while in other 
parts they are rather sparsely distributed, for the purpose of 
keeping the membrane moist. 

The pathological processes met with here may involve 
either the entire region or some single portion of it. Consid- 
erable confusion exists at present in the classification of dis- 
eases of the middle ear, and many cases in which the Eustachi- 
an canal alone is affected are classified as cases of otitis media, 
while, on the other hand, certain manifestations within the tym- 
panum dependent not upon inflammatory changes, but upon 
certain conditions of the blood vessels distributed to the parts, 
are also considered under the same title. It should be remem- 
bered that the fluid effused in a simple inflammation of a mu- 
cous membrane is an increased amount of the normal secre- 
tion of the membrane, and nothing more. The presence of a 
purulent effusion as the primary result of such an inflamma- 
tory change in a cavity lined with mucous membrane is im- 
possible ; in order that the fluid shall be purulent, infection 
must take place from the outside, or the inflammation must 
be infectious from the first, and involve not only the mucous 
membrane, but the underlying connective-tissue structures. 
The affections in which the mucous membrane alone is in- 
volved have been denominated as catarrh of the middle ear. 
From the derivation of the term, this name indicates simply 
an increased amount of secretion. Such an inflammatory pro- 
cess may involve the Eustachian tube alone, giving rise to tubal 
catarrh or catarrhal salpingitis, or both the tube and the tym- 
panum may be involved, in which case we have a tubo-tym- 
panic catarrh or salpingo-tympanitis. In this last-named dis- 
ease the inflammatory process is chiefly confined to the tube 
and seldom goes beyond the stage of congestion, changes tak- 

(296) 



EXPLANATION OF PLATE V. 

i. Appearance of the membrane in tubal catarrh. Exaggeration of an- 
terior and posterior folds. Short process prominent. Malleus handle fore- 
shortened (indicating marked retraction). Light reflex lost. No evidences of 
congestion in membrane or tympanum. 

2. The normal membrana tympani. The congestion along the posterior 
border of the manubrium was due to the prolonged presence of the speculum 
in the canal. 

3. Otitis media purulenta residua, with caries of the malleus and incus. 
There is a small perforation above the short process. The malleus handle is 
adherent to the internal tympanic wall, which is partially covered with a non- 
secreting membrane. This is wanting posteriorly over the niche of the round 
window, and anteriorly over the entrance to the Eustachian tube. 

4. Purulent otitis media, with extensive destruction of the membrana 
vibrans and displacement of the ossicles. The long arm of the incus, the 
posterior cms of the stapes, and the niche of the round window are visible. 

5. Chronic catarrhal otitis media (hypertrophic form). Malleus shaft 
rotated upon its long axis and apparently increased in breadth. There are 
several areas of calcification in the membrane. 

6. Serous effusion in middle ear, with congestion of membrana flaccida. 
The level of the fluid is distinct. This condition is often present in tubo- 
tympanic congestion. 



(296 a) 



PLATE V. 





1. 



2. 





3. 



4. 





6. 



Dr. W. A. Holden, ad. nat. del. 



EXPLANATION OF PLATE VI. 

7. Chronic catarrhal otitis media (hyperplastic changes subsequent to 
hypertrophic inflammation). Membrane retracted. Malleus handle fore- 
shortened, and apparently narrow from rotation upon long axis. Adhesions 
beneath membrana flaccida, as shown by depression above short process. 

8. Retraction of membrana tympani, with slight foreshortening of the 
malleus handle. This appearance is often observed in patients with enlarge- 
ment of the pharyngeal tonsil, who suffer from repeated attacks of tubal or 
tubo-tympanic congestion. The membrane becomes relaxed and attenuated, 
and sinks inward upon the internal tympanic wall, so that the long arm of 
the incus and the incudo-stapedial articulation are easily recognized. 

9. Intense congestion of membrana flaccida and of manubrial plexus. 
The membrana vibrans normalin parts not adjacent to extensive vascular 
plexus. Such an appearance characterizes the first stage of acute purulent 
otitis media. 

10. Acute purulent otitis media, with bulging of membrana flaccida and 
displacement of adjacent wall of meatus. The membrana vibrans is partially 
hidden, but the portion visible is normal in color. 

11. Chronic purulent otitis media. There is a perforation above the short 
process, through which a mass of granulation tissue protrudes. The mem- 
brana vibrans is wanting over the tympanic orifice of the Eustachian tube. 

12. Otitis media purulenta residua. Perforation in posterior inferior quad- 
rant. The appearance is characteristic of acute congestion as it occurs in 
these cases. The turgescence is confined to the regions richly supplied with 
blood vessels. 



(296 b) 



PLATE VI, 







9. 



10. 





11. 



12. 



Dr. W. A. Holden, ad. nat. 



PRELIMINARY OBSERVATIONS. 



297 



ing place in the cavity of the middle ear being almost entirely 
secondary to this and depending- upon the physical condition 
of reduced pressure within the tympanum, due to closure of 
the Eustachian canal. The disease is really salpingitis, which 
secondarily has given rise to certain physical changes within 
the drum cavity discernible upon otoscopic examination, and 
scarcely deserves recognition as an individual affection. The 
separation of these two varieties is made more for convenience 
in classification than for any other reason. 

In other instances the tympanum is the primary seat of a 
superficial inflammation with no involvement of the connective- 
tissue framework. In such cases the changes are usually con- 
fined to the lower portion of the tympanic cavity or to the 
atrium. The epitympanic space is not involved, and the in- 
flammatory process results in the pouring out of an increased 
amount of normal secretion, which fills, more or less com- 
pletely, the middle ear. The mucous membrane covering the 
internal surface of the membrana tympani participates in the 
process, and the membrana may be so infiltrated as to rup- 
ture from the increased pressure caused by the pent-up secre- 
tion. The rupture of the membrane in such a case depends 
not so much upon a deep-seated inflammatory process as upon 
the increased pressure to which' the membrane is subjected 
from the secretion within the cavity, although in severe cases 
it is probable that the entire thickness of the membrane is 
involved on account of the free anastomosis between the 
vessels of the inner and outer layers. After perforation has 
taken place this form of inflammation may become changed 
in character from the infection of the discharge from with- 
out, after which it runs the typical course of a purulent in- 
flammation. 

Such are the changes present in those cases where a sim- 
ple catarrhal inflammation occurs within the middle-ear tract. 
Both in tubo-tympanic catarrh and in acute catarrhal inflam- 
mation of the middle ear we may have a solution of continuity 
in the drum membrane ; in the tubo-tympanic form this rup- 
ture is due simply to the pressure of the fluid with which the 
cavity is filled. It is probable that rupture never occurs in 
these cases if the membrane is not atrophic from a previous 
pathological process. This fluid is not the result of inflam- 
mation, but of a serous transudation simply from the overdis- 
tended vessels. The fluid collects in the atrium although 



298 DISEASES OF THE MIDDLE EAR. 

transudation may take place from the numerous reduplica- 
tions in the upper part of the cavity, the fluid entering the 
atrium in obedience to the laws of gravity. In acute catarrhal 
tympanitis the transudation is of inflammatory origin, and 
this inflammatory process may be a factor of some impor- 
tance in causing the rupture of the membrane, although it 
is certainly not the principal one. Here the atrium alone is 
affected, although the tympanic vault may be involved sec- 
ondarily from subsequent infection of the discharge. 

Where the inflammation is purulent from the start we have 
those structures primarily involved which are richly supplied 
with connective-tissue elements. By recalling the anatomy of 
the tympanic cavity we remember that the vault of the tym- 
panum contains numerous duplicatures of mucous membrane, 
these being so fully developed in some instances as to com- 
pletely fill the entire epitympanic space ; the connective-tissue 
framework of these folds presents a favorable site for the 
growth of the bacteria of suppuration. When infection of 
this tissue occurs we have an inflammation set up which dif- 
fers in no respect from a cellulitis in any other portion of the 
body ; tissue necrosis takes place quite rapidly, and the secre- 
tion resulting from the inflammation is purulent in character 
from the outset. The fluid products find exit either into the 
atrium and then into the canal, or the membrana flaccida may 
be ruptured and an outlet afforded in this way, or the secre- 
tion may find its way into the mastoid cells or even into the 
cranial cavity when egress in other directions is prevented. 
Purulent inflammation occurs, as we should expect, in the 
more severe types of acute infectious diseases such as scarla- 
tina, diphtheria, variola, general pyasmic infection, etc. As 
above stated, it may occasionally follow a simple catarrhal in- 
flammation by infection of the discharge and subsequent in- 
oculation of the connective tissue in the tympanic vault 
through this secretion. 

Under the forms of chronic inflammation involving the 
portion of the conducting mechanism under consideration, we 
have those resulting directly either from a previous simple 
catarrhal inflammation or from a purulent process. 

We include in this group those cases which give the history 
of repeated attacks of acute middle-ear inflammation, but in 
whom the membrana tympani is not perforated. Other cases 
present in which the membrana tympani has been destroyed 



PRELIMINARY OBSERVATIONS. 



299 



over a small or large area and a permanent perforation re- 
mains. These again divide themselves into cases in which 
the discharge still continues after the acute disease has run 
its course, and those in which the residue of the former at- 
tack remains, the affection having either ceased spontaneously 
or yielded to treatment, restitution of the necrosed parts not 
having taken place. 

A third class of cases comprises that variety where the in- 
flammation is chronic from its inception and is characterized 
by a deposit of new tissue. To this we give the term hyper- 
plastic inflammation. Although we may find this condition 
where a previous purulent inflammation has existed resulting 
in local necrosis, it is usually met with where no such loss 
has taken place. No sharp dividing line can be drawn be- 
tween this variety and those following an acute catarrhal in- 
flammation which has failed to resolve, and to which the 
term hypertrophic is applied. 



CHAPTER XVII. 

TUBAL CONGESTION, OR TUBAL CATARRH. 
(Acute Salpingitis. Eustachian Catarrh.) 

Etiology. — This affection of the Eustachian tube usually 
arises from an acute coryza or an acute naso-pharyngitis, 
although it may be met with as a primary affection from 
exposure to cold. Occasionally it complicates light attacks 
of the exanthemata in young adults. It may depend upon 
the entrance of some irritating fluid into the Eustachian tube 
while bathing, or in using the nasal spray. Rarely it follows 
a blow upon the external surface of the body in this region. 
The chief predisposing cause is some obstructive lesion of 
the nose or naso-pharynx. The presence of adenoid vegeta- 
tions is a particularly potent factor in its causation, since 
these masses easily become engorged with blood, causing 
venous hyperasmia of the walls of the tube, narrowing or com- 
pletely closing its lumen. At the same time, the presence of 
this soft tissue in the vault of the pharynx affords lodgment 
to pathogenic bacteria inhaled during the act of inspiration, 
from which locality they easily find their way into the canal. 
Impaired general health, no doubt, renders one more liable 
to the disease. 

Pathology. — The pathological conditions are to be con- 
sidered under two heads : 

First, the actual changes present in the tubal mucous 
membrane. 

Second, the changes occurring in the middle ear depend- 
ent upon the obliteration of the tubal lumen. 

Within the tube the condition is essentially one of simple 
venous hyperasmia, or the membrane may be the seat of a 
very mild inflammation following the venous engorgement. 
The mucous membrane becomes swollen and flabby, the walls 
of the tube lying in contact with each other and adhering 
closely on account of viscid secretion. The first change of 

(300) 



SYMPTOMATOLOGY. 



301 



venous hyperemia results in a transudation of the fluid ele- 
ments of the blood* from the increased pressure. When the 
process becomes fully developed, the secretion is thick, tena- 
cious, glairy, white in color, and by its presence may occlude 
the channel completely. The changes are usually most marked 
in the cartilaginous part of the tube, the osseous segment be- 
ing but little affected. 

When the Eustachian canal is obstructed from any cause 
the air contained within the tympanic cavity disappears quite 
rapidly from absorption. This results in diminished atmos- 
pheric pressure within the tympanum, and a crowding inward 
of the drum membrane and the entire ossicular chain by the 
external atmospheric pressure. If the canal remains closed 
sufficiently long, we shall find the drum membrane so dis- 
placed that it touches the opposite internal tympanic wall in 
the region of the tip of the long process of the malleus. At 
its upper and lower poles its firm attachment prevents dis- 
placement. 

Symptomatology. — An attack of this character, occurring 
in the course of an ordinary cold in the head, is usually char- 
acterized by a rather sudden onset of the symptoms. The 
patient complains of a feeling of stuffiness or heaviness in the 
ears, as though the external meatus were occluded by a for- 
eign body, one of the most characteristic symptoms being the 
desire to insert the finger into the meatus in order to " clear 
the ear," as the patient expresses it. This manipulation is 
sometimes attended by momentary relief from the exhaus- 
tion of the air within the meatus when the finger is suddenly 
withdrawn. Sometimes, in addition to this feeling of discom- 
fort, there is a sensation of actual pain referred to the upper 
part of the pharynx or the region of the tonsil. In rarer in- 
stances this pain is complained of in the region of the larynx, 
the sensation being as though a foreign body had become 
lodged at the root of the tongue. Accompanying this, there 
is some pain radiating upward toward the ear, but when 
closely questioned we find that no actual pain is present in 
the ear. 

The hearing is considerably impaired, the diminished audi- 
tion seeming more prominent from the sudden onset of the 
attack. Subjective noises are almost always present, and may 
be exceedingly distressing. They are most frequently high- 
pitched in character, and in plethoric subjects may increase 



302 TUBAL CONGESTION, OR TUBAL CATARRH. 

in intensity with each cardiac systole. Disturbances of equi- 
librium, from the sudden increase of labyrinthine pressure, 
may be met with, although their occurrence is not invariable. 
Among the rarer symptoms to which the affection gives rise 
is a feeling of heaviness and mental torpidity. In nervous 
subjects the anxiety of the patient as to the sudden impair- 
ment of hearing power is rather characteristic. The sensa- 
tion of heaviness within the ears may not remain confined to 
this region, but may be complained of as a stiff, numb feeling 
extending over the entire side of the head. It is seldom that 
both sides are affected to the same degree, although examina- 
tion will seldom show a perfectly normal condition in the 
organ which the patient asserts is healthy. 

Occasionally cases are met with in which an attack of tubal 
congestion follows any slight exposure to cold. While not 
severe enough to narrow the lumen of the canal to an extent 
which interferes sufficiently with audition to direct the atten- 
tion of the patient to the ear, the subjective symptoms are 
very pronounced. They consist in the sensation of a foreign 
body in the pharynx, or sometimes of an acute pain at the 
root of the tongue, occasionally severe enough to interfere 
with deglutition. The patient does not complain of the ear, 
but refers all the symptoms to the pharynx or larynx. These 
manifestations are met with most frequently among neurotic 
subjects, and the attacks may be repeated at short intervals. 
Occasionally they occur in individuals who are not neurotic, 
and in these patients the symptoms are more acute, and close 
questioning will usually elicit a history of a slight impair- 
ment of audition. 

Diagnosis. — A. Physical Examination. — An inspection by 
reflected light reveals the drum membrane drawn inward 
towards the internal tympanic wall, for which reason the in- 
ferior segment seems abnormally broad from above downward, 
while at the same time the transverse diameter of this seg- 
ment seems to be increased (Fig. 92). The handle of the mal- 
leus is foreshortened, the short process is prominent and ap- 
pears lighter than normal, and in some cases it may be impos- 
sible to make out the contour of the manubrium, owing to the 
extreme degree of retraction, the shaft being entirely hidden 
behind from the prominent short process. Both the anterior 
and the posterior folds are exaggerated, the annulus tendino- 
sus is prominent, and the membrana flaccida may participate 




DIAGNOSIS. 303 

in these changes, being drawn inward upon the neck of the 
malleus and closely applied to it, although this latter condi- 
tion is not ordinarily present. The color of the membrane is 
normal, its lustre is preserved, and the light 
reflex is either absent, displaced, or multi- 
ple. The stretching to which the parts have 
been subjected causes the membrane to ap- 
pear thinner than normal, and the under- 
lying intratympanic structures may be clear- 
ly discerned through it. In the upper and FlG - 92— Retraction 

J . of membrana tym- 

posterior segment we are often able to recog- pan i from closure 
nize the long process of the incus, the in- ^^ Eustachian 
cudo- stapedial articulation, the posterior 
crus of the stapes, and sometimes the tendon of the stapedius 
muscle. The niche of the round window may also be visible. 
The lining membrane of the tympanum, as viewed through 
this thin covering, presents no evidences of congestion. The 
physical appearances are due entirely to the diminution of 
atmospheric pressure within the tympanic cavity, this region 
itself being unaffected. 

If the ear is inflated, either by means of the Eustachian 
catheter or by the Politzer method, the auscultation tube be- 
ing employed to furnish us with information concerning the 
condition of the parts, we shall find that the canal is opened 
with difficulty, the air either not entering the middle ear at all 
or only after several attempts at inflation. When the cathe- 
ter is used, the first few compressions of the bulb result in 
the production of a harsh, low-pitched, rasping sound, which 
we recognize as originating in the vault of the pharynx, and 
not depending upon the entrance of air into the middle ear. 
This is caused either by the current being forced through the 
thick viscid secretion with which the parts are covered, or 
by impinging directly upon the mucous membrane of the 
passage, which from the oedema is thrown into irregular folds 
and deflects the current of air from its original direction. As 
inflation is continued these pharyngeal sounds disappear, and 
the air enters the tube, either from the dislodgment of the 
mucus or from the displacement of the folds in the mucous 
membrane by manipulation of the catheter. Within the tube 
the current may meet an obstruction, either from an agglu- 
tination of the walls of the tube or from the lodgment of a 
mucous plug at the isthmus. When familiar with the auscul- 



3<D4 TUBAL CONGESTION, OR TUBAL CATARRH. 

tatory signs we recognize that the sound produced by the 
insufflated air is nearer the ear, and is of a less harsh charac- 
ter than when the obstruction is at the pharyngeal orifice, 
while the sensation of the sound being produced close to our 
own ear is wanting. At last we recognize the entrance of the 
current into the tympanic cavity, the quantity of air entering 
being at first small and the sound produced by its passage 
being consequently high-pitched. If the swelling is exces- 
sive, the entrance of the air into the tympanum is irregular, 
instead of occurring freely with each compression of the bulb. 
When at length the lumen has been sufficiently cleared to 
permit the free entrance of the current, the sudden replace- 
ment of the drum membrane to its normal position is recog- 
nized by the examiner by the occurrence of a sharp, almost 
metallic click, as the membrane is forced outward. 

B. Functional Examination. — Upon testing the hearing, we 
find the power of audition for the whisper markedly reduced ; 
tests with the acoumeter and watch will also show reduction 
in the hearing power, although to a relatively less degree 
than to the voice. The lower tone limit is elevated, in the 
great majority of cases being above 32 V. S., and sometimes 
two octaves higher than this. The upper tone limit is fre- 
quently reduced, or it may be normal. When reduced, the 
change is caused by pressure upon the delicate structures 
lying in the lower turn of the cochlea. The bone conduction 
is augmented especially for the low notes of the scale, Rinne's 
experiment being negative for the lower notes and a reduced 
positive result being found as we ascend the musical scale. 
The vibrating tuning fork, placed upon the vertex or upon 
the forehead, is referred to the poorer ear in almost all cases. 
These reactions may be considered as typical, and will be 
found in a very large majority of instances. Certain condi- 
tions may exist, however, which will modify them, to which 
attention should be given. In patients over forty years of 
age the tuning fork may not be lateralized to the side most 
affected, and the bone conduction may not be increased in 
comparison with the normal standard. A similar change ma) 7 
be found upon applying Rinne's test. The remarks made in 
the chapter on Physiology upon the diminution of bone con- 
duction as age advances explain this apparent deviation 
from the classical reactions. When the patient is seen very 
early, and before much retraction of the membrana tympani 



FUNCTIONAL EXAMINATION. 



305 



is present, we may find that the patient hears the lower notes 
of the scale fairly well, while at the same time bone conduc- 
tion is greatly diminished, and the upper tone limit lowered. 
This is probably due to a slight rarefaction of the air within 
the tympanum, which, according to Politzer, instead of in- 
creasing labyrinthine pressure, reduces it. It may also de- 
pend upon the particular susceptibility of the auditory nerve 
to mechanical irritation, causing a condition of hyperassthesia, 
which favors the perception of low notes, at the same time 
reducing bone conduction. 

These variations, while apparently confusing, in no way 
detract from the value of the functional examination, as they 
indicate the existence of a secondary labyrinthine condition. 
This interference with the perceptive apparatus is perfectly 
amenable to any treatment which will remove the tympanic 
disturbance upon which it depends, and its recognition is of 
importance since it shows, in any given case, a particular in- 
tolerance of the labyrinth to changes in pressure. 

It is not unreasonable to suppose that in any of these cases 
of sudden closure of the Eustachian tube the labyrinth suffers 
a certain amount of traumatism, the same as when the ear is 
exposed to the influence of sudden loud sounds, such as those 
produced by explosions, etc. It is a well-known fact that 
under these conditions a train of symptoms is found which 
we consider characteristic of concussion of the labyrinth. 
In the same manner, the sudden increase of labyrinthine pres- 
sure due to pressure of the stapes upon the perilymph may 
cause a condition of hyperesthesia of the auditory nerve, and 
change, to a marked degree, the reactions found on func- 
tional examination. When this occurs the case is one of laby- 
rinthine disease, acute in character, and readily amenable to 
treatment, and is due to the sudden and absolute closure of 
the Eustachian tube. Our functional examination reveals 
this labyrinthine condition, and should not be condemned be- 
cause it enables us to distinguish a complicating labyrinthine 
lesion, and emphasizes it rather more than the tubal stenosis. 
The clinical history and appearance of the drum membrane 
will render an error in diagnosis exceedingly rare. When 
the auditory nerve is in a condition of hyperesthesia the per- 
ception of low tones is well preserved, and it may happen 
that the lower tone limit is not elevated to the degree which 
we should expect to find in sudden closure of the Eustachian 



3 o6 TUBAL CONGESTION, OR TUBAL CATARRH. 

tube. Distressing tinnitus and vertigo, the latter being espe- 
cially prone to occur on inflating the middle ear, together 
with a lowering of the upper tone limit before inflation, 
render the diagnosis sufficiently clear. 

Prognosis. — Eustachian catarrh is ordinarily one of the 
simplest affections of the ear which it falls to our lot to meet. 
The only danger to the function of the organ lies in the tend- 
ency to a recurrence of attacks of this character. We have, 
then, to consider not only the outcome of the attack immedi- 
ately under observation, but also the result if it is allowed 
to repeat itself at short intervals. An attack of Eustachian 
catarrh ordinarily yields to treatment in from five to four- 
teen days. The hearing is completely restored only at the 
end of several weeks, but if by complete restoration we mean 
an absolutely perfect functional condition of the organ in the 
ordinary acceptance of the term, the patient notices nothing 
abnormal about the ear, either as regards the integrity of 
hearing or the presence of subjective noises after a lapse of 
five to fourteen days. After an individual has suffered from 
several attacks of this affection it will be found that the hear- 
ing gradually becomes impaired, each exacerbation reducing 
it somewhat, at first imperceptibly, but later in the course of 
the disease to a degree distinctly recognizable both by the 
patient and by those with whom he is brought in contact 
in his daily vocation. This is caused by the development 
within the tympanic cavity of a slowly progressive inflam- 
matory process, dependent upon the malposition of the con- 
tained parts for a long period of time. When the drum 
membrane is indrawn at frequent intervals by successive at- 
tacks of tubal stenosis, and remains in this position for a 
considerable period, it becomes stretched, and assumes an ab- 
normal position more easily than does the normal mem- 
brane. The tendon of the tensor tympanic muscle from re- 
peated relaxation becomes shortened, and exerts its influence 
in maintaining the irregularity of curvature which the mem- 
brane has assumed. This shortening of the tendon of the 
tensor causes the tip of the manubrium to press upon the 
internal tympanic wall. This source of mechanical irritation 
gives rise to an inflammatory process, ultimately resulting in 
the development of adhesions in other parts of the tympanic 
cavity, and producing a chronic catarrhal otitis media. Start- 
ing in this manner, we may have a simple hyperplastic pro- 



TREATMENT— INFLATION. 



307 



cess developed, or the condition so much dreaded by the 
otologist and laity — sclerosis within the tympanic cavity. 
While, therefore, a simple tubal catarrh, if left to itself, will 
in all probability disappear at the end of a certain interval, 
we should never lose sight of the danger of frequent recur- 
rence, and it is our duty not only to relieve the single attack, 
but also to direct our efforts toward preventing a repetition. 

Treatment. — The treatment of the affection will embrace 
measures directed to 

First, the acute attack. 

Second, prophylaxis. 

When a patient suffers from the disease under considera- 
tion our first efforts are to relieve the subjective noises, the 
impairment of hearing and the feeling of discomfort within 
the ear, of which he complains. This is best accomplished by 
restoring the drum membrane to its normal position by some 
method of inflation. In adults there is no question but that 
the employment of the Eustachian catheter is the most effect- 
ive means at our disposal. In children, the Eustachian tube 
being relatively short and catheterization being attended by 
considerable difficulty, resort may be had to inflation by the 
Politzer method. When the catheter is used we shall find, as a 
rule, that the mucous membrane of the nares and naso-pharynx 
is intensely tender, owing to the inflammation in this region 
which has caused the aural disease. To overcome this and 
to render the process of catheterization less disagreeable to 
the patient, a ten-per-cent solution of cocaine should be first 
sprayed into the anterior nares, the anaesthesia being com- 
pleted by the passage of a cotton-tipped probe through the 
nares, the cotton having been saturated with cocaine solu- 
tion. The catheter is then introduced in the ordinary man- 
ner, when, by compressing the inflating bulb several times, 
the membrane is replaced. Care should be exercised in per- 
forming this manipulation to compress the bulb gently at first, 
as suddenly filling the tympanic cavity with air at this period 
is liable to cause intense dizziness, and the patient may even 
fall in a dead faint. By performing the inflation slowly, and 
gradually increasing the force until the tube becomes perme- 
able, this will be avoided. If the patient performs the act of 
deglutition at the moment the bulb is compressed, the air en- 
ters the cavity more easily. The relief is instantaneous when 
the malposition of the membrane is corrected, and the mental 



308 TUBAL CONGESTION, OR TUBAL CATARRH. 

depression so common to these patients disappears at once. 
As the condition will undoubtedly return in from three to 
twenty-four hours after the first inflation, and from the sudden 
reappearance of the symptoms the individual may consider 
himself even worse than before treatment, it is always well 
to call attention to the probability of this recurrence. It is 
exceptional that a single inflation will permanently relieve 
the condition and the consequent symptoms. Sometimes the 
tube is so tightly closed that the air enters the middle ear 
only after repeated attempts at inflation. When this is the 
case the auscultation tube usually reveals the cause. This 
may be an oedema of the tubal walls, but more frequently is 
the lodgment of a plug of thick mucus in the tubal orifice, 
which completely prevents the entrance of air. This ob- 
struction may be removed by wiping the tubal mouth with 
a pledget of cotton, the extremity of the cotton carrier be- 
ing curved like the Eustachian catheter. After this has been 
done inflation becomes a very simple matter. The drum 
membrane being replaced, our next efforts should be directed 
to the abnormal condition within the tube. The site of the 
greatest oedema is usually the pharyngeal orifice, a part easily 
accessible to instruments introduced through the lower mea- 
tus of the nose. To control this oedema an astringent should 
be applied to the tubal mouth by means of a pledget of 
cotton, the cotton holder being bent in the form of the Eus- 
tachian catheter. None is better than a solution of nitrate of 
silver varying in strength from ten to thirty grains to the 
ounce. The degree of concentration suited to any particular 
case can be learned only by experiment, but in general the 
more acute the process the stronger the solution to be used. 
Concerning the application of vapors to the Eustachian tube, 
I do not believe this procedure to be wise in the early stages, 
as their action usually increases rather than diminishes the 
local congestion. The application of astringents seems not 
only more rational, but, clinically, is followed by better re- 
sults. The operation of inflation and topical applications to 
the pharyngeal orifice of the tube should be repeated at first 
daily, and later, as improvement becomes more marked, the in- 
terval should be prolonged to several days, until complete res- 
toration both of physical condition and of function takes place. 
In some cases it will be impossible to open the Eustachian 
tube by any method of inflation. Here resort must be had to 



TREATMENT— BOUGIE— VAPORS. 



309 



the Eustachian bougie. I am in the habit of using for this 
either the bougie catheter (shown in Fig. 93), or, in the ab- 
sence of this, the ordinary Eustachian catheter, through which 
a piece of No. 5 piano wire is passed. The extremity pro- 
truding from the catheter is roughened slightly 7 with scissors 




Fig. 93. — Author's bougie catheter for Eustachian tube 



and armed with a pledget of cotton, care being taken to wind 
this so firmly that it can not be displaced. The wire is then 
drawn into the catheter so that the cotton-tipped end alone 
protrudes. Remembering that the diameter of the Eustachian 
tube varies from three quarters of a millimetre to two milli- 
metres, the size of this cotton pledget should certainly not ex- 
ceed the last-named dimension, and when used for the first 
time it is well to make it considerably smaller than this. The 
opposite end of the wire is bent at a right angle at a point one 
inch and a half from the outer funnel-shaped extremity of the 
catheter. This, then, enables us to estimate the distance that 
the bougie has passed into the tube at any time. The bougie 
catheter or the ordinary Eustachian catheter armed in this 
way is introduced in precisely the same manner as in per- 
forming the operation of inflation, after which the catheter is 
firmly fixed in position by the fingers, and the piano wire is 
made slowly to advance in the direction of the Eustachian 
tube, the patient being requested to swallow at frequent in- 
tervals, both to relax the faucial muscles and to increase as 
much as possible the diameter of the canal. After the instru- 
ment has passed about an inch beyond the pharyngeal orifice 
it will apparently meet an obstruction which will be recog- 
nized as the isthmus of the canal, the region at which the 
lumen is normally less than in other locations; aside from this 
any obstruction encountered constitutes a pathological condi- 
tion. In passing the instrument beyond such an obstruction 
the greatest gentleness must be employed, lest the mucous 
membrane of the canal be wounded and decidedly uncomfort- 
able symptoms supervene. Most frequently in tubal catarrh 
the obstruction is confined to the cartilaginous portion of the 
tube, the osseous segment remaining free. The use of the 



3 io TUBAL CONGESTION, OR TUBAL CATARRH. 

cotton pledget as a dilator has a twofold advantage. In the 
first place, the metal parts of the apparatus may be sterilized 
in boiling water, and if the pledget is formed of sterilized 
cotton it is impossible to introduce any pathogenic bacteria 
during the operation. A pledget of cotton tightly twisted in 
this manner increases in volume when moistened. If, there- 
fore, an obstruction is met with, and the instrument, after en- 
gaging it, is allowed to remain for a short time, considerable 
dilating force is exerted by the absorption of moisture, and 
a twofold advantage gained. Concerning the danger of the 
pledget of cotton becoming detached in the lumen of the 
tube, it can only be said that this has never occurred, and if 
ordinary care is used in the preparation of the apparatus no 
such accident can follow. The necessity of thoroughly boil- 
ing the instrument immediately before using it can not be too 
strongly emphasized. 

Where the lining membrane resists these efforts the appli- 
cation of astringents to the mucous membrane beyond the ori- 
fice is indicated. These may be made by moistening the cot- 
ton pledget previous to its introduction with a solution of 
nitrate of silver of various strengths, beginning with a weak 
solution, about five to ten grains to the ounce, and gradually 
increasing the strength until the desired result is obtained. 
Under no condition should inflation be practiced immediately 
after the introduction of a bougie, since a slight abrasion of 
the mucous membrane may furnish an avenue of entrance to 
the air and submucous emphysema may result. 

When the condition fails to improve at the end of ten days, 
stimulating applications in the form of vapors may be em. 
ployed with advantage. The object of such applications is 
temporarily to increase local hypersemia, and, by means of this 
increased blood supply, to restore the tone of the parts and 
cause them to resume their normal condition. It makes but 
little difference what vapor is employed, so long as we bear 
in mind the object to be attained. Any preparation which is 
a local stimulant and vaporizes at the ordinary temperature 
may be used. Tincture of benzoin, oil of eucalyptus, menthol, 
iodine, camphor, and various aromatic oils may all be used 
with success ; the vapor of alcohol, of ether, or of chloroform 
is also efficacious. The best method of exhibition is by means 
of a device by which the current of air on its way to the 
tympanum is made to pass over the volatile substance, thus 



TREATMENT— PROPHYLAXIS. 3 { i 

becoming charged with a certain amount of the volatile prin- 
ciple. Either Roosa's or Lucas's bulb, or the bottle devised 
by Dayton, or the instrument of the author (see Fig. 94), may 
be employed, according to the choice of the operator. 



Fig. 94. — Author's middle-ear vaporizer. The bottle is fitted with a double stop- 
cock, and either air or medicated vapor can be insufflated at will by turning 
the thumb-screw. 

If the author's apparatus is employed, it is well, instead of 
filling the reservoir with the fluid, to place a little cotton 
saturated with the preparation to be used within this, as in 
the event of the accidental breaking of the reservoir by a 
sudden motion of the patient no damage is done to the gar- 
ments either of the patient or of the physician. . 

My own preference when vapors are employed is first to 
clear the tube as perfectly as possible by inflating with air 
alone, after which the inflation is continued with the medi- 
cated air. The strength of the application varies with the na- 
ture of the substance and with the condition of the parts. The 
menthol and camphor may be used in alcoholic solution in 
the strength of one drachm of each to the ounce of alcohol, 
or the solvent may be tincture of iodine, if the stimulating 
effect of the iodine seems indicated. The other drugs men- 
tioned should be used in the same relative proportions. A 
third local stimulant of considerable value is a mixture of the 
oil of eucalyptus and pine-needle oil in equal proportions. Oil 
of cloves may be used in strength of half a drachm to the 
ounce of alcohol. When iodine is used, the officinal tincture 
is the preparation best suited for the purpose. Ether and 
chloroform should be used in exceedingly small quantities, as 
they are extremely irritating, and their use is attended by 
considerable discomfort. 



312 TUBAL CONGESTION, OR TUBAL CATARRH. 

The advantages of inflating first with air and subsequently 
with a medicated vapor, instead of using the medicated air from 
the first, lie in the fact that by this means very little of the medi- 
cated air is brought in contact with the mucous membrane of 
the nose and naso-pharynx, and local irritation here is reduced 
to a minimum. When medicated vapors are used the catheter 
is always the instrument to be employed for their introduc- 
tion if this is possible. Occasionally, however, we may be 
obliged to resort to the Politzer method of inflation ; but if 
possible this should be avoided. 

Under prophylactic measures must be included attention 
to the mucous membrane lining the nasal passages and the 
pharyngeal space. Inquiry into the history of these cases 
shows that the patients are subject to frequent " colds in the 
head or throat." If any departure from the normal condi- 
tion is present in these regions it should be dealt with radi- 
cally. The removal of enlarged faucial and pharyngeal ton- 
sils, the reduction of a hypertrophic process within the nares, 
either by chromic acid, the galvano-cautery, or any other ap- 
propriate measure, and the actual removal of any obstructive 
deformity of the septum or of an extensive hypertrophy of 
turbinated bodies which has failed to respond to less radical 
measures, will be necessary in order to prevent repeated at- 
tacks of similar nature. When no deviation from the normal 
standard exists aside from the condition dependent upon the 
acute attack, the general hygiene of the patient must be in- 
vestigated. The daily use of the cold bath, preferably of the 
plunge bath," is essential ; but if this for any reason is contra- 
indicated, the cold sponge bath may be substituted. The use 
of all-wool underwear and a regulation of the habits of life 
will ordinarily enable us to prevent successive attacks. 

Ordinarily the local treatment occupies the most promi- 
nent position in the mind of the physician ; but it can not be 
too strongly urged that careful attention to the hygienic sur- 
roundings of the patient are of quite as much, and frequently 
of more, importance than the employment of the topical ap- 
plications. 



CHAPTER XVIII. 

TUBO-TYMPANIC CONGESTION. — ACUTE TUBO-TYMPANITIS. — 
TUBO-TYMPANIC CATARRH. 

In this condition, in addition to the changes already men- 
tioned as occurring in the Eustachian tube, there is present a 
congestion of the mucous membrane lining the middle ear, 
dependent upon the physical changes which the tubal occlu- 
sion causes rather than upon any actual inflammatory process 
within the tympanum. 

./Etiology. — The same conditions which produce a tubal 
catarrh may cause the affection under consideration. The 
exact condition which results in any individual case depends 
both upon the activity of the exciting cause and upon condi- 
tions within the tympanum peculiar to the particular case. 
If the tympanic vessels are wanting in tone from some sys- 
temic condition, or have been in a state of engorgement for a 
considerable period from local causes, the sudden occlusion 
of the tubal lumen will effect certain changes within the mid- 
dle ear recognizable upon physical examination, and active 
in the production of certain subjective symptoms. The ex- 
citing causes of the attack are usually the same as those of 
simple tubal catarrh, and their repetition here is unnecessary. 

Pathology. — We may find within the tympanum a simple 
engorgement of the vessels supplying the mucous membrane, 
leading to a general hyperemia of the inner tympanic wall 
and, to a lesser extent, of the drum membrane itself, this being 
most marked along the course of the vascular plexus. This 
congestion may result, in two conditions — either one of hyper- 
secretion with the accumulation of mucus within the tym- 
panic cavity, or in a simple serous exudation due to the tenu- 
ity of the vessel walls. This condition of the vessels is usu- 
ally of constitutional origin and is not pncommon in those 
affected with a gouty diathesis or with chronic cardiac, he- 
patic, or renal disease. In the membrana tympani this ve- 

(313) 



314 TUBO-TYMPANIC CONGESTION. 

nous congestion is evidenced bv an increased amount of blood 
within the veins. As the vascular network is most rich in 
the upper and posterior segment close to the perphery and 
along the manubrium mallei, these localities show, upon in- 
spection, deviations from the normal color. It is true that 
stasis is the first stage of any inflammation, but the disease 
under consideration does not usually progress further than 
this first stage. The reduplications of mucous membrane in 
the upper part of the cavity may also be involved, the effused 
serum draining into the atrium or bulging the upper part of 
the membrane. 

Symptomatology. — The symptoms already enumerated 
under tubal catarrh undergo slight modifications when the 
cavity of the middle ear is involved. Instead of the " stuffy " 
feeling so characteristic of Eustachian occlusion, these pa- 
tients frequently complain of distinct pain in the ears, while 
the feeling of heaviness and numbness about the head is less 
marked. Pain is particularly well marked when the vault of 
the cavity is involved. The impairment of hearing is usually 
not as sudden, nor is it as pronounced as in simple occlusion 
of the tube. This may perhaps be explained upon the theory 
that the slight swelling of the membrana tympani renders its 
displacement by atmospheric pressure less easy, and conse- 
quently the ossicles are not crowded together as firmly as 
when no obstacle is offered to the displacement of the drum 
membrane. Tinnitus is present, and may be distressing ; it 
is prone to be influenced by the position of the patient, and 
is most complained of when the horizontal position is as- 
sumed, as this posture increases the vascular engorgement. 
When there is fluid within the middle ear the sufferer fre- 
quently complains of great variations in hearing according to 
the position of the head. When sitting quietly he may be 
conscious of a slight impairment, but if the head is suddenly 
bent backward this impairment becomes marked, disappear- 
ing again when the erect position is resumed. The reason is 
that the effused fluid is capable of a certain amount of motion 
within the middle ear, and when the head is bent backward 
flows to the postero-inferior part of the cavity, covering the 
round and oval windows and interposing an obstacle to the 
entrance of sound waves. 

Another quite characteristic symptom is the occurrence 
of a bubbling or snapping sound when the patient blows the 



SYMPTOMATOLOGY— DIAGNOSIS. 



315 



nose forcibly, or sometimes during the act of deglutition. 
During the performance of these acts the tubal obstruction 
momentarily becomes less complete, and the current of air 
entering the tympanum passes through the fluid and gives 
rise to the sound. 

Autophony is also frequently complained of, while sub- 
jective noises may vary considerably according to the posi- 
tion of the head, being usually more severe in the recumbent 
position. A condition of the hyperassthesia of the auditory 
nerve may occur in these cases, causing certain sounds to be 
painful. The sounds producing a painful impression are 
high-pitched, but ordinarily not those of the highest pitch, 
since the occlusion of the niche of the round window by the 
fluid lowers the upper tone limit of sound perception con- 
siderably. 

When the ear has been inflated by the patient himself, 
either accidentally or by design, the hearing immediately im- 
proves to a surprising degree, while the retrograde change 
may be equally sudden after the act of deglutition. 

Diagnosis. — A. Physical Examination. — The inspection of 
the parts by means of reflected light will reveal appearances 
which vary considerably in the different cases according to 
the actual conditions present. The distinctive feature, as con- 
trasted with a simple tubal stenosis, lies in the fact that the 
drum membrane or the internal tympanic wall shows evi- 
dences of circulatory changes, which are absent when the tube 
alone is affected. The position of the drum membrane is 
usually that of moderate retraction, the extent of this not be- 
ing as great as when the tube alone is affected. The mem- 
brana tympani varies slightly from the normal color ; instead 
of being pearly white, it is changed to either a dull white 
throughout, or it is of a light pinkish-white tinge. At the 
periphery and along the handle of ttye malleus the change of 
color is decidedly more marked and is of a dull-reddish hue. 
These changes in color along the manubrium and at the pe- 
riphery do not indicate a true inflammatory condition, but a 
venous congestion simply, with a consequent prominence of 
the veins forming the manubrial and peripheral plexus. This 
dull-reddish color is sometimes very prominent above the 
short process from the congestion within the tympanic vault 
and is indicative of the possibility of the process, progressing 
to suppuration. The pinkish tinge of the entire membrane 



316 TUBO-TYMPANIC CONGESTION. 

which we sometimes observe is due not to changes in the 
membrana tympani itself, but to congestion of the internal 
tympanic wall. The rays of light pass through the mem- 
brana tympani and illuminate the internal wall of the middle 
ear, which is in these cases considerably reddened. This col- 
ored background gives to the membrana tympani the pink- 
ish tinge described, but the change in color depends upon 
congestion within the cavity rather than upon any changes 
within the membrana tympani itself aside from those already- 
mentioned as occurring in the venous plexus of the mem- 
brane. 

The malleus handle appears foreshortened according to 
the degree of collapse, but seldom to the extent seen in sim- 
ple Eustachian occlusion ; the anterior and posterior folds 
are more prominent than normal ; from stasis the membrane 
may appear thicker than normal, and may partially lose its 
lustre. On account of the displacement, the light reflex is 
changed both in position and shape, and may be multiple. 
These changes are recognized ordinarily when no effusion has 
taken place within the tympanic cavity. If, owing to the 
abnormal fullness of the vessels, a certain amount of transu- 
dation has taken place within the tympanum, the degree of 
depression is not apt to be as marked. Instead of this, a close 
inspection will reveal the membrana tympani, presenting in 
its inferior segment a slightly yellowish color, the lustre of 
the membrane being diminished, while the density is increased. 
This dull look is wanting in the upper part of the membrane, 
the illuminating rays penetrating it and revealing more or 
less distinctly the condition of the inner tympanic wall ; and 
if the membrana tympani is thin, frequently enabling the 
observer to recognize the long process of the incus on the 
posterior crus of the stapes (Fig. 95). The appearance is due 
to a collection of fluid in the lower part of the tympanic cav- 
ity, the result of serous transudation. Not infrequently we 
observe the line of demarcation between the upper and lower 
areas as sharp and distinct, appearing as a fine line which 
traverses the membrana tympani transversely (see colored 
plates). This line marks the level of the fluid in the tympanic 
cavity, and may be mistaken for a hair stretching across the 
surface of the drum membrane. By tilting the head of the 
patient forward or backward, it is often possible to observe 
changes in the direction of the fluid line. If the patient prac- 



DIAGNOSIS— FUNCTIONAL EXAMINATION. 



317 



tices auto-inflation, the current of air upon entering the tym- 
panic cavity will bubble up through the contained fluid, and 
upon inspection these bubbles are visible (Fig. 96) ; they 
change their position when the patient swallows or forces 
more air into the tympanic cavity. Naturally their presence 
is an unquestionable evidence of fluid. In cases where the 
drum membrane has been thickened from preceding inflanv 





Fig. 95. — Moderate retraction of mem- Fig. 96. — Posterior segment of mem' 

brana tympani. Incudo-stapediai ar- brana tympani bulged by fluid in the 

ticulation visible in upper posterior tympanum. Bubbles of air in the fluid 

quadrant. are visible through the membrane. 

mation it may be so dense as to prevent the recognition of 
these air bubbles upon ocular inspection. In such instances 
several bright points of light are often seen upon the surface 
of the membrane below the level of the fluid. These multi- 
ple reflexes are indicative of the presence of fluid, although 
they must not be relied upon as absolutely characteristic of 
this condition. Inflation with the catheter or by Politzer's 
method will reveal, through the diagnosis tube, the character- 
istic bubbling as soon as the air enters the middle ear. When 
serum alone is present the rales produced by the bursting of 
the bubbles will be sharp and high-pitched ; when a certain 
amount of mucus is mixed with the serum, the sound will be 
of lower pitch and of less intensity and the explosive sounds 
will follow each other at less frequent intervals. The absence 
of rales upon auscultation can not be taken as a positive evi- 
dence that no fluid is present in the middle ear. A small 
amount of effusion may lie entirely out of the air current and 
give no sign of its presence. Again, the fluid may be incap- 
sulated in a fold of the mucous membrane, and thus be unaf- 
fected by the operation of inflation. 

B. Functional Examination. — Upon examining the patient 
with reference to the power of audition w r e shall find dimin- 
ished air conduction, both for sharp sounds — such as the 
watch and acoumeter — and for the conversational voice and 
whispered speech, the defect for the vocal sounds being 
relatively more marked than for isolated sharp sounds. The 



3 18 TUBO-TYMPANIC CONGESTION. 

tuning fork will show an elevation of the lower tone limit, 
while the Galton whistle indicates a reduction of the upper 
tone limit. This latter will be more marked when fluid is 
present and occupies such a position as to cover the round 
and oval windows. The vibrating tuning fork, placed upon 
the forehead, is usually lateralized to the more affected side in 
cases of bilateral disease, or toward the affected side when 
only one ear is involved. Absolute bone conduction for a 
fork of two hundred and fifty-six or five hundred and twelve 
double vibrations per second, is usually increased, although 
sometimes it may be slightly less than normal. While this 
latter condition indicates the involvement of the perceptive 
apparatus, the labyrinthine lesion depends upon the process 
within the middle ear, and will disappear when the tympanic 
condition becomes normal. The presence of fluid in the mid- 
dle ear may modify the results of the functional tests, and 
render an exact diagnosis of the condition of the perceptive 
apparatus impossible until it has been removed by therapeu- 
tic or surgical measures and the conducting mechanism has 
been restored as nearly as possible to its normal condition. 

Prognosis. — In many of these cases, especially in children, 
the parts return to a completely normal condition without 
treatment. In adults, while spontaneous recovery occurs in 
a certain proportion of instances, it is probable that the func- 
tion of the organ is not completely restored. Aside from 
spontaneous resolution, Ave may have developed, as a result 
of this process, a chronic otitis media, the persistent conges- 
tion of the parts ultimately resulting in an inflammatory pro- 
cess of the chronic type. This may result either in an hyper- 
trophy of the mucous membrane lining the cavity, the redu- 
plications increasing in number and in density, or occasionally 
we have developed a true hyperplastic inflammation, in which 
the connective-tissue framework of the lining membrane of 
the middle ear becomes firm, the interfibrillary substance be- 
ing absorbed, and a sclerotic condition is the result. This 
process is usually more pronounced in the region of the oval 
and round windows than elsewhere. The membrane of the 
Eustachian tube may undergo similar changes. When the 
hypertrophic changes occur within the tympanum the Eusta- 
chian tube is also affected, its calibre being so narrowed that 
ventilation of the tympanum is interfered with. In the hyper- 
plastic or sclerotic inflammation the result is to increase its 



TREATMENT— INFLATION— INCISION. 



319 



calibre rather than to diminish it. In those cases where the 
circulatory system is impaired from diathetic causes, the effu- 
sion in the tympanic cavity may increase in amount when the 
mucous membrane of the upper air passages is congested as 
the result of exposure to cold or of some disturbance of the 
primas vice, diminishing in quantity or disappearing when the 
patient is in a fairly normal condition. 

Treatment. — In the acute stage the measures already men- 
tioned under the treatment of tubal catarrh are to be adopted. 
Proper attention to clothing and hygienic surroundings and 
the treatment of the upper air passages, surgically or other- 
wise, is of the greatest importance in preventing recurrent 
attacks. 

In addition to this we have to deal with the congestion 
within the tympanum itself, and when effusion is present our 
treatment must be of such character as to produce either 
its absorption or its exit by mechanical means. For the 
relief of the venous engorgement local bloodletting stands 
pre-eminent. The abstraction of from two to four ounces of 
blood from the region immediately in front of the tragus is 
frequently followed by a complete cessation of the unpleasant 
symptoms and restoration of function. When seen early, this 
method may prevent the effusion of fluid into the middle ear. 
Next we should try to prevent this transudation by restoring 
the intratympanic pressure as nearly as possible to its normal 
standard. This is to be effected by inflation of the middle 
ear, either by the Politzer method or by the use of the Eusta- 
chian catheter. Authorities vary considerably as to the pro- 
priety of using the air douche in acute congestion of the tym- 
panum. To my mind, there is no question but that inflation 
is beneficial in a very large proportion of these cases, and fre- 
quently shortens the duration of the disease, preventing tran- 
sudation of serum by supporting the intratympanic vessels. 
The relief to the subjective symptoms is also very marked, 
and in no instance have I seen the condition aggravated by 
the operation, even when relief did not follow. After the 
effusion of serum has taken place, local bloodletting is ordi- 
narily useless unless actual pain is present, and we have rea- 
son to fear that tne process may become inflammatory. 

After effusion has taken place our efforts should be di- 
rected toward its removal. Two ways are available : either 
evacuation by incision through the drum membrane, or re- 



320 TUBO-TYMPANIC CONGESTION. 

moval through the Eustachian tube. The objection to early v 
incision of the membrana tympani is the supposed tendency 
to recurrence when the fluid is evacuated in this manner. 
Unless the transudation is considerable in amount and causes 
much discomfort, it is well to attempt its absorption, reserv- 
ing incision of the drum membrane for persistent cases only. 
The prime factor influencing the absorption of the fluid is a 
patulous condition of the Eustachian tube, thus relieving the 
venous turgescence and permitting the passage of the effusion 
into the lymphatics. The restoration of the tube to a patulous 
condition is effected by the use of the catheter, the bougie, 
the application of astringents to the orifice of the tube, or in- 
flation with medicated vapors. These measures have been de- 
tailed under tubal catarrh. When the condition has existed 
for a considerable time the mucous membrane of the middle 
ear may not readily take up the fluid. Here inflation with any 
medicated vapor which will stimulate the lining membrane 
may accomplish the desired object. For this purpose we may 
use menthol or camphor in the proportion of one drachm to 
an ounce of alcohol, the vapor of the oil of eucalyptus in full 
strength, or even alcohol vapor alone. It is best, when the 
fluid is not too viscid, to evacuate a certain amount of it 
through the Eustachian tube by means of the air douche. To 
do this the head should be inclined forward and toward the 
unaffected side during the performance of the operation, and 
occasional attempts at deglutition should be made, as this act 
renders the tube more patulous and permits the fluid to be 
displaced more easily. An effusion of this character should 
yield to treatment in not less than fourteen days, the air douche 
being administered at first daily, and, as the condition im- 
proves, at longer intervals. If a decided impression has not 
been made upon the fluid at the end of this time it is unwise 
to delay longer, and the membrana tympani should be incised. 
The same plan should be adopted even at an earlier period if 
the patient can not be kept under observation sufficiently long 
to insure a complete restoration by the milder measures al- 
ready indicated. Considerable difference of opinion exists as 
to the precise location and the extent of incision through the 
drum membrane. To my mind the question should be de- 
cided on general surgical principles. The object sought is 
perfect drainage and a rapid and perfect restoration of the 
parts to their normal condition. These ends can be attained 



TREATMENT-INTERNAL MEDICATION. 



32: 



only by a free and extensive incision which will evacuate 
all the fluid and leave the parts in a condition favorable to 
immediate union throughout the entire line of section. In 
order that the drainage may be perfect, the lowest point of the 
opening must lie near the inferior pole of the drum membrane. 
Since the upper and posterior part of the cavity is the most 
capacious, an effusion sufficient in amount to demand evacua- 
tion usually causes a bulging of the drum membrane in this 
locality. I prefer, therefore, to insert an exceedingly sharp 
but delicate knife close to the periphery of the membrana at 
a point opposite the short process ; the knife is then carried 
downward close to the periphery to the lowest point of attach- 
ment of the membrana tympani. The section lies entirely 
within the clear membrane, and should not wound the carti- 
laginous ring. When considerable congestion is present it is 
advisable to secure local depletion by carrying the knife suffi- 
ciently inward to make it impinge upon the internal tympanic 
wall so as to divide the soft parts which cover it, throughout 
the entire extent of the incision through the drum membrane. 
If the parts above the short process are intensely congested 
the incision is to be extended upward so as to enter the vault 
and deplete the engorged 
tissues. In these cases it 
is usual to incise from be- 
low upward (Fig. 97). A 
few vigorous efforts at in- 
flation by means of the 
Politzer method clears the 
cavity completely of fluid, 
the divided parts fall read- 
ily into place, approxi- 
mation being practically 
perfect, and it is not un- 
usual to find complete 
union at the end of thirty- 
six hours. The only pos- 
sible untoward result fol- 
lowing this procedure is accidental infection at the time of 
the operation. To avoid this the canal should be first syringed 
with a solution of bichloride of mercury (1 to 8,000), while 
the instruments employed should be sterilized by boiling. 
After the fluid has been evacuated the canal should be closed 




Fig. 97. — Method of incising membrana tym- 
pani to evacuate fluid in the atrium (natural 
size). 



322 TUBO-TYMPANIC CONGESTION. 

by a plug of aseptic cotton and the patient should on no con- 
dition interfere with it. Carried out in this manner, there 
is absolutely no danger in adopting this kind of treatment for 
an effusion of any kind within the tympanic cavity. 

Nothing has been said concerning the administration of in- 
ternal remedies. I have little faith in the beneficial action of 
any drug for the correction of the condition under considera- 
tion. As a prophylactic measure it is well, upon the disap- 
pearance of the attack to guard against recurrence by the 
exhibition of drugs supposed to be particularly efficient in 
overcoming a lymphatic diathesis. This is especially true in 
the case of children. The administration of the iodide of iron 
in doses of four to eight grains three times daily, together with 
hypophosphites, will do much in the direction of causing a 
spontaneous disappearance of the deposits of lymphatic tissue 
in the naso-pharynx and pharynx. Often after surgical inter- 
ference, it is well to employ these remedial agents for a period 
of a month or six weeks to insure the permanency of the re- 
sult. Where the condition depends upon a disturbance of the 
vascular apparatus, as in arterio-capillary sclerosis, or upon a 
renal lesion, the proper treatment of the general disease may 
do much to diminish the local process. The application of 
astringent remedies to the tympanic cavity, either through 
the Eustachian tube or through an artificial opening in the 
drum membrane, is not, I think, indicated in this condition, 
since we are dealing not with an inflammation, but with an 
obstruction to the venous flow. 



CHAPTER XIX. 

ACUTE CATARRHAL OTITIS MEDIA. 

This term is applied to an actual inflammatory condition 
within the middle ear, resulting in an increase in the normal 
secretion. In this way it differs from the process just de- 
scribed. Why in one patient we should have a simple con- 
gestion of the tympanic lining, and in another an acute in- 
flammatory process, the factors of causation being similar in 
the two cases, it is impossible to state. It seems that the 
difference must depend somewhat upon the power possessed 
by the individual to resist the invasion of pathogenic bacteria 
and also upon the virulence or degree of infection in the in- 
dividual case. It is certain that venous stasis plays a part in 
the causation, as in this condition any membrane is particu- 
larly susceptible to the absorption of bacteria. The infection, 
then, of an individual in perfect health might result in the 
first stage of inflammation simply or an obstruction to the 
venous flow with possible effusion of serum from mechanical 
causes alone. In an individual less robust the infective pro- 
cess would be carried one step farther, and we should have, 
following the stage of congestion, an actual inflammatory 
process developed. Here again comes the question as to 
why in certain instances this inflammatory process results in 
the formation of mucous secretion, and in others in the forma- 
tion of pus. We have in the structure of the middle ear a 
sufficiently clear explanation of this, I think. Remembering 
that the upper part of the cavity contains a large amount of 
connective tissue, we should expect infection in this region 
to be followed by an inflammation of the cellular type, while 
infection of the lower portion of the cavity would result in 
a simple catarrhal inflammation of the lining mucous mem- 
brane. Clinical experience bears out this theory. It is this 
last-named process that occupies our attention at present. 

^Etiology. — An acute external otitis may complicate mea- 
sles or a cold in the head, or may be caused by the introduction 

(323) 



3 2 4 



ACUTE CATARRHAL OTITIS MEDIA. 



of fluids into the middle ear through the Eustachian tube 
while bathing, or through the use of the nasal douche. Vio- 
lent efforts at clearing the nostrils may occasionally cause the 
affection in the same manner. Any abnormal condition of 
the upper air passages, particularly the presence of an en- 
larged pharyngeal tonsil predisposes to this disease. Ex- 
posure to cold or wet may bring on an attack without any 
other symptoms referable to the upper air tract being pres- 
ent. Traumatic rupture of the membrana tympani may lead 
to an infection of the atrium and a simple inflammation of its 
lining membrane, although in most of these instances the in- 
flammation is purulent in character. 

Pathology. — The pathological changes have been de- 
scribed in what has already gone before. The inflammation 
is confined to the superficial layer of the lining membrane of 
the tympanum, the basement membrane escaping. Most fre- 
quently only the lower part of the tympanic cavity is in- 
volved. The reduplications lying within the vault are con- 
gested and swollen, but the process does not go farther than 
this. As the result of the inflammation the action of the mu- 
cous glands is stimulated, and their secretion, mixed with the 
transuded serum, fills the tympanic cavity with a turbid fluid, 
rather thick in consistence and containing much mucin and 
holding in suspension desquamated epithelial cells. The 
changes involve the mucous layer of the membrana tympani, 
which becomes swollen and, by exfoliation of its superficial 
cells, leaves the fibrous layer exposed ; this becomes infil- 
trated also, and from the pressure of the accumulated secre- 
tion may give way at one point, permitting the pent-up fluid 
to flow into the canal. Spontaneous perforation in these cases 
probably depends as much upon the increased pressure as 
upon the actual inflammatory process involving the deeper 
layers of the drum membrane. The Eustachian tube, while 
partaking of these pathological changes to a certain degree, 
is not involved to the same extent as in a simple salpingitis, 
the activity being more directed toward the lining membrane 
of the middle ear. 

Symptomatology. — The symptoms vary considerably, ac- 
cording to the age of the patient. For convenience we will 
consider the disease first as affecting adults, and later as af- 
fecting children. 

A. In Adults. — The early symptoms may be so slight as to 



PATHOLOGY- SYMPTOMS IN ADULTS. 325 

pass unnoticed. They consist in a feeling of fullness and 
stuffiness in the ear, dependent upon the occlusion of the 
Eustachian canal. This sensation is soon followed by pain in 
the ear referred to the tympanic cavity, and of steadily increas- 
ing severity. The degree of pain is ordinarily sufficiently acute 
to prevent sleep, provided the attack occurs at night. The 
pain is usually distinctly localized, and seldom partakes of 
the diffuse character found in inflammation of the external 
meatus, while its severity enables it to be distinguished from 
that due to closure of the Eustachian tube. The pain is usu- 
ally most severe upon lying down, owing to the determina- 
tion of blood to the head when this position is assumed. Sub- 
jective noises of high-pitched character manifest themselves 
quite early, but are not complained of, on account of the 
severity of the pain. Impairment of hearing is at first slight, 
but steadily increases, and may reach an exceptionally high 
degree. When the stage of hypersecretion is reached the pain 
subsides gradually, being replaced by a feeling of fullness or 
heaviness in the side of the head. Each act of deglutition is 
painful, and the patient is conscious at these times of the 
entrance of air into the tympanum, its passage through the 
fluid producing bubbling sounds, while the movement which 
it causes in the intratympanic structures is attended by lan- 
cinating pain on account of the swollen condition. The body 
temperature is seldom elevated, but from the severity of the 
pain considerable prostration may follow. At any period 
varying from twelve to forty-eight hours spontaneous rup- 
ture of the membrana tympani may take place, as evidenced 
by the appearance of a sero-mucous discharge from the ex- 
ternal auditory meatus, and an abrupt cessation of the pain. 
In many cases rupture does not take place, and the disease, 
having run its course, leaves within the tympanic cavity a 
collection of sero-mucus, which then produces the character- 
istic symptoms of an intratympanic effusion. If the drum 
membrane is exceedingly dense and does not yield to the 
pressure of the fluid, the vault of the tympanum may become 
involved secondarily, and a purulent inflammation supervene. 
In still other instances, where no spontaneous outlet is effect- 
ed, the lining membrane of the mastoid cells becomes in- 
volved. The patient complains of severe pain behind the 
ear, gradually spreading to the side of the head. This in- 
volvement is usually associated with an elevation in body 



326 ACUTE CATARRHAL OTITIS MEDIA. 

temperature and an increase in the severity of all the symp- 
toms. 

The discharge may cease spontaneously at the end of a 
few hours or days. It may continue as a sero-mucous dis- 
charge, or by exposure to the air it may become infected, its 
character then changing to a purulent secretion. When this 
occurs, the infection may spread to the middle ear, involving 
the structures situated within the vault, and may then follow 
the ordinary course of a chronic purulent inflammation of 
the middle ear. In other cases the discharge of the fluid is 
followed by a complete cessation of all symptoms, the open- 
ing of the membrana tympani closing spontaneously and the 
parts returning to their normal condition. 

B. In Children. — In* very young children the symptoms 
characteristic of an acute catarrhal inflammation of the mid- 
dle ear may be of so severe a type as to incline one to the 
opinion that the child is suffering from a much graver dis- 
ease. The attack usually comes on at night. The infant at 
first tosses about in bed and throws the arms upward over 
the head, usually toward the affected side, although this is 
not invariable. After a short period of disturbed sleep the 
child wakens and gives evidence of intense suffering. The 
temperature is frequently exceedingly high, and may reach 
106 , but usually varies from 102 to 104 . From the very 
fact that the ear is usually the organ least suspected, we may 
remain in complete ignorance of the cause of this rise in tem- 
perature until, after several hours, a sero-mucous discharge 
appears in the meatus. This is usually accompanied by a 
cessation of all symptoms, the child dropping off to sleep and 
the temperature gradually falling. In certain cases the at- 
tack may be ushered in by repeated convulsions and by vom- 
iting, simulating very closely an attack of meningitis. With 
the appearance of discharge in the ear pain usually ceases, 
and in many cases the temperature becomes perfectly nor- 
mal. This is not the invariable rule, however, even though 
drainage is free. The drum membrane of a child is ex- 
ceedingly thin and' yields easily to the outward pressure 
of the fluid, rupturing before the inflammation within the 
tympanic cavity has ceased. An elevation of the tempera- 
ture, therefore, may continue for a few days after perfectly 
free drainage is secured. .When this is the case the tem- 
perature is apt to be either remittent or intermittent, the 



SYMPTOMATOLOGY— IN CHILDREN. 



327 



elevation in the afternoon reaching 103 or 104 in many 
cases. 

The character of the discharge both in adults and children 
varies according to the period of the disease. During the first 
few days the fluid is large in amount, turbid from the mixture 
of epithelial cells, and rather viscid in consistence from the 
presence of mucin. The viscidity of the discharge offers an 
obstruction to its free exit through the small opening in the 
drum membrane and obstructive symptoms may occur. As a 
rule the discharge is much more profuse in children than in 
adults and contains a greater number of epithelial cells. When 
the case progresses favorably the secretion gradually dimin- 
ishes in amount, becomes thinner and more watery, and finally 
disappears entirely. If proper attention is not paid to clean- 
liness the fluid may become infected in the auditory canal, the 
infection may spread to the tympanic cavity, and a purulent 
otitis media supervene from inoculation of the connective- 
tissue structures in the tympanic vault. This accident need 
never happen if proper attention is paid to cleanliness. The 
presence of the secretion in the meatus tends to soften and 
remove the epithelial matter, thus leaving a denuded surface, 
through which infection may take place and localized or dif- 
fuse otitis externa follow. 

After the appearance of the discharge the constitutional 
symptoms may again become severe if the opening through 
the drum membrane becomes occluded either by thick mucus 
or as the result of the reparative process ; especially is this 
true when a case progresses rapidly toward recovery and an 
acute naso-pharyngitis occurs as the result of exposure to cold. 
From this cause the inflammatory process within the middle 
ear becomes augmented and a sudden increase in the amount 
of secretion takes place. The opening through the drum mem- 
brane is not of sufficient size to permit of free drainage, and 
the symptoms already described in the earlier part of the chap- 
ter are repeated. A relapse of this character is always to be 
feared, since there is danger of secondary inflammation of the 
mastoid cells. Occlusion of the opening in the membrana tym- 
pani, even for a short time, may also result in mastoid involve- 
ment by any fresh access of inflammatory process. 

The impairment of hearing and the subjective noises usu- 
ally diminish after the pressure within the tympanum is re- 
lieved by the passage of the contained fluid into the auditory 



328 ACUTE CATARRHAL OTITIS MEDIA. 

meatus. Necrosis of the osseous tympanic wall or of the os- 
sicula themselves does not take place in simple catarrhal otitis, 
although the condition is frequent in the purulent variety. 
These sequelae will be considered under a chapter on puru- 
lent otitis media. 

Diagnosis. — A. Physical Examination. — An inspection of 
the canal and membrana tympani in the early stages will re- 
veal a distinctly hyperasmic condition of the drum membrane, 
most marked in the region of the manubrium, the redness 
shading off gradually into the normal color of the part. The 
structures above the short process — that is, in Shrapnell's 
membrane — may also present a reddish color quite early in 
the disease, since the blood vessels of the membrana tym- 
pani are richly distributed in this region and venous conges- 
tion may be marked. The hyperaemia is distinguishable from 
the vascular congestion present in tubo-tympanitis from the 
fact that the vessels themselves do not stand out prominently, 
but the redness is diffuse, merging gradually into the normal 
pearly white color of the membrana tympani, while in tubo- 
tympanitis the outline of the vessels is distinctly marked and 
there is a line of demarcation between the hyperasmic areas 
which are identical with the normal vascular plexus and the 
remainder of the membrane. The position of the drum mem- 
brane may be normal, although quite frequently it is moder- 
ately depressed ; extensive collapse of the part upon the in- 
ternal tympanic wall does not occur as a rule. At a later 
period the entire membrana tympani, particularly the mem- 
brana vibrans, is uniformly reddened ; the lustre is wanting ; 
the landmarks may be obscured on account of oedema; the 
short process of the malleus, however, is 
seldom completely hidden, even in severe 
cases, if careful search is made for it. At 
this period effusion has usually taken place, 
the result being to force the drum membrane 
Fig s^Modert outward into the canal. The displacement 
. bulging of entire is usually most marked in the upper and pos- 
panL rana ym " .terior part (Fig. 98) ; in children, and in 
adults where the membrana tympani is more 
obliquely placed than usual, the membrana seems to be con- 
tinuous with the postero-superior wall of the meatus, narrow- 
ing the fundus of the auditory canal, this region being con- 
verted into a small quadrangular area of not more than one 




DIAGNOSIS— PHYSICAL EXAMINATION. 



329 



quarter the normal size (Fig. 87). Such a narrowing is quite 
as characteristic of bulging of the drum membrane as a dis- 
tinct globular mass filling the fundus of the canal. A point 
to be remembered in this connection is that the entire mem- 
brana tympani bulges as a whole, the change in position not 
being limited to the membrana flaccida. This is of consider- 
able diagnostic importance when we remember that inflam- 
mations of a purulent character usually involve the upper 
portion of the cavity first, and the presence of fluid causes a 
protrusion of the membrana tympani above the short process 
of the malleus. More attention will be paid to this in a later 
chapter. 

After the discharge has made its appearance, an inspection 
of the ear will reveal the canal filled with sero-mucous fluid. 
Upon removing this, the surface of the drum membrane will 
be seen covered with a dense white lustreless coating. This 
is due to a necrosis of the superficial epithelial layer, and may 
be easily removed by means of the cotton pledget, when the 
external surface of the membrana tympani will be seen to be 
red and swollen. The point of rupture should be searched 
for carefully, but where the canal is swollen it is sometimes 
difficult to locate it exactly. Usually it is found in the in- 
ferior segment, either just below the manubrium or in the 
anterior portion close to the periphery of the drum mem- 
brane, When examined immediately after rupture has taken 
place, the discharge pours out so rapidly that it is difficult to 
determine exactly the location of the opening. Nor is this of 
importance, provided we ascertain that it is of sufficient size 
to admit of free drainage. The presence of a muco-serous 
discharge in the canal is sufficient evidence that perforation 
has taken place. The use of the Politzer air bag or of the 
Eustachian catheter will, when the ear is inflated, afford us a 
certain evidence of this from the sharp, high-pitched perfora- 
tion w T histle. This sound is modified by the passage of the 
current through the fluid. Before perforation has taken place 
inflation gives simply the sounds characteristic of fluid with- 
in the tympanum. 

In children we are not uncommonly called upon for an 
opinion immediately following an attack of " earache." From 
the history, we learn that the morning following an attack a 
slight amount of moisture was present upon the pillow, and 
that the margin of the orifice of the meatus was coated with 



33Q 



ACUTE CATARRHAL OTITIS MEDIA. 



a yellowish incrustation. At the time of our examination no 
discharge is present in the canal, the only symptom from 
which the child is suffering being an elevated temperature. 
Inspection reveals congestion of the entire membrana, while 
at one point we are able to make out a localized haemorrhagic 
deposit. The signification of this appearance is that the at- 
tack was of only slight severity, and that spontaneous rupture 
occurred. The pressure was relieved by this means of exit 
to the effusion, and the minute opening has already closed. 
Our efforts here are confined to the prevention of subsequent 
attacks, as the immediate condition is undergoing sponta- 
neous resolution. 

B. Functional Examination. — Ordinarily the pain is so great 
in these cases that the functional examination is seldom made. 
We shall find, however, that the tuning fork placed in the 
median line of the skull will be referred to the affected side ; 
air conduction for the lower portion of the scale will be want- 
ing or much diminished. The upper tone limit may be nor- 
mal or slightly reduced, and absolute bone conduction will be 
increased. The power of audition, both for speech and for 
sharp sounds, will also be much reduced. 

Prognosis. — These cases terminate favorably, as a rule, 
often without treatment. Purulent otitis media and involve- 
ment of the mastoid cells occasionally occur. The latter con- 
dition may supervene whether perforation takes place or not. 

If perforation does not take place, the case may fail to 
undergo complete resolution, and a certain amount of fluid 
may remain in the tympanum, causing impaired hearing and 
in a persistence of subjective noises. If the fluid is absorbed, 
the mucous membrane may fail to return to its normal con- 
dition and become the seat of a chronic inflammatory process 
either of an hypertrophic or proliferative type. From the 
long-continued presence of fluid within the tympanum the 
drum membrane may become relaxed, and after the fluid has 
disappeared this change in tension may give rise to subjective 
noise, and to an impairment of audition from the ease with 
which it is depressed when the atmospheric pressure within 
the middle ear is diminished. 

When perforation has taken place, the opening may close 
spontaneously ; or it may persist, leaving the internal wall of the 
tympanum exposed ; or the ligamentous structures within the 
middle ear may undergo cicatricial contraction, displacing the 



TREATMENT— INSTILLATIONS— INCISION. 



331 



parts and interfering seriously with their function. This lat- 
ter condition usually results when the inflammation becomes 
purulent in character. In a certain proportion of cases a 
simple catarrhal inflammation of the lower portion of the tym- 
panum becomes purulent from infection through the Eusta- 
chian canal before the perforation takes place. This is par- 
ticularly prone to occur when the process is active and the 
parts within the tympanic vault are excessively hyperasmic ; 
the disease then follows the same course as acute purulent 
otitis. 

Serious inflammation of the intracranial structures prob- 
ably never occurs when the disease is of a catarrhal type. In 
children, where the tympanic roof is exceedingly thin, it is 
not improbable that meninges in the immediate neighbor- 
hood are congested ; but the process stops here, and a true 
meningitis is not developed. 

Treatment. — The first indication is the relief of pain. The 
patient should be put to bed, a saline cathartic administered, 
and complete relief from pain secured by the administration 
of an opiate. In adults a hypodermic injection of ten to 
twelve minims of Magendie's solution is the most convenient 
form of administration, while in children the camphorated 
tincture of opium is to be preferred. It can not be too 
strongly insisted upon that complete relief from pain should 
be secured for a period of at least five or six hours, during 
which time attempts should be made to abort the inflamma- 
tion. This end is attained more certainly by local blood- 
letting than by any other measure. From two to four ounces 
of blood should be drawn by means of the artificial leech 
from immediately in front of the tragus, or two natural 
leeches may be applied in this location if the surgeon prefers 
to make use of them. 

The application of dry heat is certainly of value in re- 
lieving pain, and does not interfere with measures directed 
toward aborting the attack. The most convenient means of 
applying this is by means of the hot-water bag or Japanese 
pocket stove. Moist heat is objectionable, since it favors 
venous congestion, softens the tissues, and hastens local ne- 
crosis, rather aiding the development of the process we desire 
to abort. Theoretically cold applications would be of benefit ; 
but the presence of any fluid of low temperature within the 
external auditory canal is painful under ordinary circum- 



332 ACUTE CATARRHAL OTISIS MEDIA. 

stances, and when the parts are acutely inflamed it is unbear- 
able. 

It is decidedly unwise to instill any oily solutions into the 
canal for the relief of pain. This practice is very common, 
and only serves to obscure the parts when an examination is 
made, and possesses absolutely no therapeutic value. A so- 
lution of carbolic acid in glycerin, in the proportion of one 
to twenty, is sometimes of service, and there is no objection 
to its use. The same may be said of aqueous solutions of 
morphine, atropine, and cocaine. The relief obtained is usu- 
ally temporary, and we simply prolong the duration of the 
disease by their use. 

Failing to abort the attack, and the pain continuing, we 
should not delay incision of the membrana tympani. It is of 
great importance, I believe, to perform this operation early, 
and not to wait until it is evident that spontaneous rupture 
will take place unless the fluid is evacuated artificially. The 
local depletion secured by the operation is of great value, 
while the relief to pain is usually immediate and permanent. 
If, then, at the end of twelve hours, the patient still com- 
plains of pain, the membrana tympani should be freely incised. 
When distinctly bulging, the centre of the incision should be 
over the most prominent point ; but in the absence of any par- 
ticular sign to guide us, the knife should be entered close to 
the periphery of the membrana tympani, just below the pos- 
terior fold, and the membrana completely divided by a curved 
incision downward to its inferior pole, the incision lying en- 
tirely within the clear membrane and parallel to its line of 
insertion. It is also wise to incise at the same time the mem- 
brane of the internal tympanic wall to secure additional de- 
pletion. This procedure is of value even when but a small 
amount of transudation has occurred. The operator should 
be exceedingly careful to use a knife which will pass through 
the membrane by its own weight, under which circumstances 
scarcely any pain is experienced. Attempts to anaesthetize 
the membrana tympani by a strong solution of cocaine scarcely 
diminish the pain instant upon the operation, although where 
the superficial epithelium has been cast off they may be of a 
certain amount of value. 

Before the operation the field should be rendered aseptic 
in the manner already described in the consideration of a 
similar operation in the chapter on tubo-tympanitis. After 



TREATMENT— IRRIGATION. 



333 



the membrana has been divided, irrigation with a warm anti- 
septic solution relieves whatever pain may be present, and 
aids the divided vessels to return to their normal calibre. If 
section is performed early we may cut short the attack, the 
incision closing at the end of thirty-six or forty-eight hours, 
and the symptoms subsiding completely. When the oper- 
ation has been postponed until the process is well advanced, 
the discharge ordinarily continues for a period of two to ten 
days, and may be quite profuse at first. During the period 
of discharge which may follow either spontaneous rupture or 
evacuation by surgical interference, the canal must be kept 
thoroughly cleansed. This end is best attained by the fre- 
quent use of the ear syringe in the hands of an attendant. 
The cleansing fluid may be either water w T hich has been 
boiled and allowed to cool until it can be tolerated by the 
patient, or a mild antiseptic solution may be used. The fre- 
quency with which irrigation may be performed will depend 
upon the amount of discharge. At first the ear may require 
cleansing six times daily ; the interval is gradually prolonged 
as the discharge becomes less viscid and diminished in quan- 
tity. It is important that these cases should be seen at first 
daily by the surgeon himself, at which time any fluid within 
the tympanic cavity should be thoroughly evacuated by the 
use of the air douche, the parts being afterward dried with 
absorbent cotton. It has been my practice, where I have 
been able to observe the case daily, to insufflate a small 
amount of boric acid into the canal after cleansing, thus se- 
curing a permanently aseptic condition of the parts, and 
guarding against carelessness on the part of the attendant, 
which might result in infection. Under no condition is a 
large amount of powder to be introduced into the ear, and 
unless the ear is inspected daily it should be a cardinal rule 
that no powders are to be used. When the discharge has 
nearly ceased, and is so small in amount that it does not ap- 
pear in the external meatus when the ear is left undisturbed 
for twenty-four hours, more prompt recovery takes place if 
fluid applications are discontinued entirely, the discharge 
being removed by absorbent cotton, after which a small 
amount of boric acid is dusted over the parts. This suffices 
to preserve an aseptic condition, while a complete absence of 
fluid causes a more speedy return to a normal condition. 

In cases of spontaneous rupture the opening may be so 



334 



ACUTE CATARRHAL OTITIS MEDIA. 



small that drainage is not perfect. When these cases are 
seen late in the course of the disease, our first efforts should 
be directed toward enlarging the opening and thoroughly 
cleansing the tympanic cavity by driving out the contained 
fluid with the air douche. If this does not suffice, the tym- 
panum may be washed out with a 
saturated solution of boric acid by 
means of the middle -ear syringe 
(shown in Fig. 99). If examination 
shows the lining mucous membrane 
j Jl to be considerably thickened, the 

instillation of a few drops of a two- 
per-cent solution of nitrate of silver 
or a four-per-cent solution of sul- 
phate of zinc suffices to correct the 
condition. In many cases a single 
application is followed by a com- 
plete cure. The medicinal solutions 
are instilled either with the middle- 
ear syringe or a simple middle-ear 
pipette of glass. Care should be 
taken when nitrate of silver is used 
to begin with a very weak solution, 
since the patient may possess a pe- 
culiar idiosyncrasy toward this drug, and the reaction fol- 
lowing its application may be severe. If, after the first trial, 
we find the parts tolerant, the strength may be gradually 
increased until the desired results are obtained. When the 
pharynx is filled with hypertrophied lymphatic tissue, we find 
that the case is particularly liable to a relapse when the dis- 
charge has almost ceased. There is no reason why the pres- 
ence of an otitis media of this character should influence us 
to delay the removal of the hypertrophied lymphatic tissue 
after the acute aural symptoms have subsided. Its removal 
will be necessary to prevent subsequent similar seizures, and 
will certainly favor a rapid termination of the present attack. 
After the opening of the membrana tympani is closed, the 
patient should be kept under observation until the parts pre- 
sent a perfectly normal appearance. A certain amount of re- 
laxation of the drum membrane and of the intratympanic lig- 
aments follows an inflammation of this character, and may 
result in the formation of adhesions in the tympanum unless 




Fig. 99. 



Blake's 
syringe. 



middle-ear 



TREATMENT— IRRIGATION. 



335 



certain measures are instituted to prevent it. Inflation of 
the middle ear should be practised at first daily, and subse- 
quently at longer intervals, until all traces of congestion dis- 
appear and the membrane retains its normal position. 

In these cases, and also in instances where the membrana 
tympani remains intact, a certain amount of fluid may be left 
in the middle ear. The application of stimulating vapors to 
the lining membrane of the cavity will hasten absorption of 
this residual fluid. For this purpose nothing is better than 
the vapor from an alcoholic solution of menthol, sixty grains 
to the ounce. Oil of eucalyptus, or pine-needle oil of the 
strength of a drachm to the ounce, may also be employed, 
the vapor being conveyed to the middle ear through the 
Eustachian catheter. The introduction of simple or medicated 
steam into the tympanum has fallen somewhat into disuse. 
It possesses no advantages over dry vapors, and its use is at- 
tended with a certain amount of discomfort to the patient 
and is tedious for the operator. 

Subjective noises may persist for a considerable time after 
hearing has returned to a practically normal condition. The 
question of a secondary inflammation of the labyrinth presents 
itself at this period. From observation of a large number of 
patients we find that the labyrinth is seldom seriously in- 
volved in this disease. The subjective noises ultimately dis- 
appear when the mucous membrane of the tympanum returns 
to an absolutely normal condition. The failure of this symp- 
tom to disappear need give rise to no uneasiness. When the 
noises are particularly distressing, relief is obtained by the 
administration of dilute hydrobromic acid in doses of thirty 
to forty-five minims two or three times daily. The suscepti- 
bility of the receptive centres is blunted, and after the noises 
have once disappeared they seldom recur. It is wise to avail 
ourselves of the use of the drug, since the continued stimula- 
tion of this part of the receptive apparatus rather militates 
against an early disappearance of the symptom. 



CHAPTER XX. 

ACUTE PURULENT OTITIS MEDIA. 

The presence of pus in any locality depends upon a ne- 
crotic process involving the deeper tissues of the region. 
In the middle ear the upper portion of the tympanic cavity 
presents an exceedingly favorable site for the development 
of a purulent inflammation, since in this region considerable 
connective tissue is present, forming the framework of the 
mucous reduplications of the tympanic vault, as well as of the 
ligamentous bands fixing the ossicles to the walls of the tym- 
panum and uniting them to each other. 

A purulent otitis media primary in character is indicative 
of an infection in this region, as distinguished from a similar 
process involving the lower portion of the tympanic cavity. 

JEtiology. — In order that tissue necrosis may take place, 
the organism producing it must possess a certain amount of 
virulence. One of the most common causes, therefore, of 
purulent otitis media is some acute infectious disease. The 
affection most frequently followed by the disease under con- 
sideration is scarlatina, although it may appear during the 
course of pneumonia, epidemic influenza, variola, typhus, or 
cerebro-spinal meningitis. It often follows the introduction 
of fluid into the middle ear through the Eustachian tube. 
The extension of an external otitis, either diffuse or circum- 
scribed, may set up a purulent otitis media, access to the 
middle ear being gained through the Rivinian segment. The 
rupture of the drum membrane, either from any foreign body 
introduced into the meatus or by violent inflation of the tym- 
panum, may be followed by a similar result. 

Occasionally vegetable molds developing in the canal in- 
volve the middle ear by continuity. A purulent inflammation 
in any other part of the body may infect the tympanic cavity 
secondarily, although this is an uncommon occurrence. As 
stated in the previous chapter, the disease may follow an 

(336) 



PATHOLOGY. 



337 



acute catarrhal otitis media by infection of the exudation 
either through the Eustachian tube or after it has gained an 
exit through the drum membrane and appeared in the ex- 
ternal meatus. 

Pathology. — The first stages of the process consist in a 
hyperasmia of the affected parts. The folds in the vault of 
the tympanum become engorged with blood, increase in vol- 
ume, and often fill the space completely, shutting off all com- 
munication with the atrium. This period of congestion is 
followed by a transudation of the fluid elements of the blood 
and a migration of white blood cells. Following this, local 
necrosis takes place, the tissue breaking down with the forma- 
tion of pus. As the result of the local oedema the blood sup- 
ply of the ossicular chain is considerably interfered with, 
and bony necrosis may occur quite early. This usually takes 
place first in the incus, on account of the limited blood supply 
in proportion to its size and the fact that its nutrient vessels 
pursue such a course as to be subjected to pressure quite 
early in the attack. The surrounding walls of the tympanum 
may also become involved, although this rarely occurs early 
in the disease. Occasionally the process may start as an 
acute osteitis either of some portion of the ossicular chain or 
of the bony walls of the tympanum, the soft parts being in- 
volved secondarily. This condition is occasionally met with 
in patients suffering from tuberculosis. 

After the inflammation is fully developed and the parts 
have become engorged with blood, transudation of the fluid 
elements of the blood takes place, together with migration of 
the white blood-corpuscles which pass out of the vessels into 
the surrounding tissue ; the fluid transuded naturally gravi- 
tates to the lowest portion of the cavity. The exact position 
occupied by the fluid will depend upon the particular forma- 
tion of the tympanum in any individual case ; occasionally the 
mucous folds are so developed that the transudation is con- 
fined and does not enter the general tympanic cavity. It 
will be remembered that the long process of the incus passes 
downward from the body of the ossicle into the atrium ; this 
fact plays an important part in the cases under consideration, 
since, when the tissues within the tympanic vault are much 
swollen, the long process of the incus forms a natural drain 
along which the fluids may pass into the lower portion of the 
tympanic cavity from the space above. We find that where 
23 



338 ACUTE PURULENT OTITIS MEDIA. 

the inflammatory products from the vault collect in the atrium 
and subsequently perforate the membrana tympani this per- 
foration lies in the upper and posterior quadrant close to the 
tympanic ring- and just below the incudo-stapedial articula- 
tion. The fact that perforations located in this region are per- 
sistent and that the inflammatory processes developed here 
are specially painful is a fact that has long been noted ; its 
particular significance, however, has been explained but lately. 
Sometimes, owing to the topography of the organ, the upper 
part of the cavity is completely divided from the lower por- 
tion. The inflammatory products in these cases can not pass 
along the descending arm of the incus into the atrium, and 
therefore crowd the upper portion of the membrana tympani 
outward. This bulging of the membrana flaccida is particu- 
larly characteristic, and is sometimes present to such a degree 
that the distended portion sinks down over the membrana 
vibrans, partially or completely concealing it from view. I 
have seen one instance in which the bulging was so extensive 
that the membrana flaccida protruded from the meatus and 
might easily have been mistaken for a polyp. Upon incision 
a large amount of fluid was evacuated, retraction took place, 
and examination revealed the opening in the superior quad- 
rant just above the posterior fold. It is probable that those 
cases of otitis media in which the atrium seems to be the pri- 
mary seat of purulent inflammation are really instances in 
which the inflammatory products have passed from the vault 
into the atrium along the long- process of the incus, as it is 
hardly possible for a purulent inflammation to originate in a 
cavity whose mucous lining is closely applied to the bony 
walls. Where evacuation does not occur, either spontaneously 
or at the hand of the surgeon, the fluid may dissect the soft 
tissues of the canal for a certain distance along the superior 
and posterior wall, since in this region the periosteum of the 
canal is directly continuous with the membrana flaccida and 
is but loosely attached to the bony margin of the meatus. 
This gives rise to a sinking of the postero-superior wall of the 
meatus and a narrowing of the deeper portion of the canal. 
The pus may burrow along the entire length of the wall and 
make its appearance in the post-auricular region as a soft, 
fluctuating swelling. This is particularly liable to occur in 
children, where the tissues are less firmly attached to the 
parts beneath, and the membrana tympani is so superficially 



SYMPTOMATOLOGY. 339 

placed. Cases of this class are particularly prone to mastoid 
complication. 

Examination of a large number of cases teaches us that the 
mastoid is usually involved before the soft parts covering the 
postero-superior wall of the canal become detached from the 
underlying bone. Hence, evidence of a collection of fluid in 
this region constitutes an almost pathognomonic sign of mas- 
toid inflammation. In children, where the purulent collection 
has dissected off the posterior wall of the canal and formed a 
post-aural abscess, the periosteum on the outer surface of the 
temporal bone may become detached unless the fluid is freely 
evacuated, and infection of the intracranial structures may 
take place either through the mastoid squamous fissure which 
remains open for a considerable period after birth, or a local- 
ized caries or necrosis of the squamous portion may take place 
on account of interference of the blood supply, and direct in- 
fection follow. Several cases of this character have been re- 
ported, and it has fallen to my lot to witness two * — one in a 
child and one in an adult. The involvement of the cranial con- 
tents in this manner is the exception, the infection usually tak- 
ing place either through the tympanic roof or through one of 
the large venous sinuses in the immediate neighborhood of the 
middle ear. Either condition may occur by a transmission 
of the infecting material through the communicating venous 
channels, or local caries may take place and a large amount 
of pus be brought in contact with the surface of the meninges 
or enter directly into the blood current through one of the 
large sinuses. 

Symptomatology. — The characteristic symptom of an 
acute purulent otitis is sudden and excruciating pain deep 
within the ear. Attending this we have a decided elevation 
of temperature, the thermometer registering from 101 to 
103 , severe headache, constipation, and marked constitu- 
tional depression. The hearing becomes rapidly impaired, 
there is often distressing tinnitus, and in some cases vertigo. 
When the disease occurs in children the symptoms are even 
more marked, the attack being frequently ushered in with 
general convulsions. The pain changes quickly from one lo- 
calized within the ear to a rather diffuse headache upon the 
affected side. In severe cases even in adults delirium is occa- 

* Archives of Otology, vol. xxi, p. 253. 



340 



ACUTE PURULENT OTITIS MEDIA. 



sionally present. High temperature in marked contrast to 
the very moderate increase observed in an acute catarrhal 
inflammation indicates the more profound constitutional infec- 
tion. The pain continues unabated unless relieved artificially 
until the inflammatory products are evacuated. This may 
not occur for several days if the condition is not interfered 
with. The occurrence of discharge offers some relief to the 
pain, although it does not entirely remove it, since the tissues 
are so cedematous that the opening is seldom large enough 
to permit free drainage. The fluid that fills the auditory 
canal is usually at first sero-purulent, but quickly changes to 
a distinctly purulent character. Involvement of the mastoid 
cells may occur before the appearance of discharge or at 
a subsequent period. In either event it is characterized by 
increased pain, and an augmentation in the severity of all of 
the general symptoms. The location of pain changes some- 
what and is referred to the region immediately behind the 
auricle rather than to the ear itself. Involvement of the struc- 
tures within the cranial cavity is usually characterized by 
an increase in the temperature, violent delirium, convulsive 
movements followed by paralysis or paresis, either upon the 
corresponding or the opposite side, according to the particular 
area involved. When invasion of one of the large sinuses of 
the dura mater takes place either from the middle ear itself 
or from the subsequent mastoid involvement, symptoms of 
pyaemic infection appear. These are a sudden high tempera- 
ture, frequently reaching 105 or 106 , with an equally sudden 
return to normal or even to subnormal, profuse sweating, and 
rigors. These changes in temperature are repeated at inter- 
vals varying from a few hours to one or two days. 

Evidences of extension to the labyrinth are the sudden 
appearance of dizziness, nausea, and either absolute deafness 
for all notes or complete loss of perception for certain portions 
of the musical register, usually the high notes of the scale. 
Extension in this direction is rather unusual, a fact which 
would suggest that the vascular communication between the 
middle ear and the labyrinth through the intervening bony 
wall is not as extensive as the investigations of Politzer * 
would cause us to believe. 

Diagnosis. — A. Physical Examination. — Recognition of this 

* Arch, fur Ohrenheilk., vol. xi, p. 237. 



DIAGNOSIS. 3 4 T 

condition in its very early stages is of the utmost importance, 
since the disease is always a severe one, being dangerous not 
only to the function of the organ, but often to life itself. 
Particular attention should be given to an inspection of those 
parts lying above the short process of the malleus whenever 
severe pain in the ear is complained of. It is the rule that in 
the very early stage that portion of the membrana tympani 
alone, lying above the short process of the malleus, is the 
only part which presents the slightest departure from the 
normal appearance. Here close inspection will reveal the 
fact that the membrane is distinctly congested, presenting a 
deep dull-red color characteristic of a high degree of venous 
engorgement of the underlying structures. This hyperasmia 
does not extend below, and frequently not as far as the poste- 
rior fold, and, if a hasty examination be made, may entirely 
escape observation. It is in this very early stage that prompt 
measures may serve to abort the attack ; hence the stress 
which is laid upon the physical characteristics. 

When viewed somewhat later, well-marked engorgement 
of these structures is seen to be present, the membrana flac- 
cida being pushed outward . and somewhat 
downward (Fig. ioo). The entire region is of 
a deep-red color, the parts being cedematous, 
the external surface moist, and the normal lus- 
tre entirely wanting. The tumefaction may be 
so great as to actually sink downward into the 
canal to the level of the short process, or may FlG - ioo.— Acute 

. . TTT1 n i iii purulent otitis 

overhang it. When well advanced, the hyper- media ; bulging 
semia becomes general, and involves the entire ° f membrana 

, ' o 11 flaccida. 

tympanic membrane. sometimes the short 
process may be completely hidden by the oedema of the sur- 
rounding parts, although this landmark can usually be found 
if sought for carefully. The outline of the manubrium is 
almost always lost. 

In cases complicating scarlatina, or any disease where the 
infection has been sudden and violent, an appearance which 
may deceive is one in which the membrana tympani presents 
a dead-white color. This is due to a necrosis of the superfi- 
cial epithelium covering it, the loss of lustre being character- 
istic of the condition. This superficial layer is easily removed 
by the cotton-tipped probe, and reveals the red membrane 
beneath. Where fluid has drained into the lower portion of 





342 ACUTE PURULENT OTITIS MEDIA. 

the tympanic cavity the entire membrana tympani may bulge 
into the canal instead of presenting a localized bulging area 
at the upper part. The appearance then does not differ from 
that shown in Fig. 98. The secretion may be so confined by 
the mucous folds within the tympanum as to present, upon 
examination, several tumefied masses lying in the fundus of 
the canal close to the superior wall. These may be two or 
three in number, according as the fluid is confined in the an- 
terior and posterior pockets of the membrane, or has entered 
these and the median space known as the pocket 
of Troelsch as well (Fig. 10 1). Inspection of 
such a case, where a clear history can not be 
obtained as to the length of time the disease 
has lasted, is misleading, the bulging areas 
being frequently mistaken for masses of granu- 
Fig. 101.— Acute lation tissue. Where perforation has taken 
med/a^ Arid P^ ace spontaneously, we most frequently find 
confined in the the opening in the posterior portion of the 
membrane * & membrane, just above the centre and near its 
peripheral attachment. It may also appear 
above the posterior fold and be entirely within the membrana 
flaccida. When this occurs it usually forms the apex of an 
irregular conical projection from Shrapnell's membrane, the 
margins of the perforation being swollen and irregular in 
outline. 

Forcing air into the middle ear through the Eustachian 
tube before perforation has taken place may not reveal the 
presence of fluid, since the collection may be confined entirely 
to the vault. After perforation has taken place, even vig- 
orous efforts at inflation may not force air through the open- 
ing in the drum membrane, and give rise to the characteristic 
perforation whistle. It may even fail to force any secretion 
from the tympanic cavity on account of the extreme swelling 
of the lining membrane. 

B. Functional Examination. — The functional examination in 
these cases reveals a condition identical with that described 
in the preceding chapter on acute catarrhal otitis media. 

When the labyrinth is encroached upon by extension 
through the oval or round window, we find, in addition, the 
diminution in bone conduction and loss of perception of upper 
notes of the scale. 

Prognosis. — An otitis media of this variety can only ter- 



PROGNOSIS. 



343 



minate in spontaneous recovery without loss of tissue when 
the inflammatory process does not progress beyond the stage 
of congestion. When once pus is formed it must be evacu- 
ated, and hence resolution is impossible after this period. 
With the evacuation of the fluid the perforation may heal and 
the parts be restored to their normal condition. Such a for- 
tunate termination is seldom to be looked for, however, un- 
der the most favorable conditions, and cases which are un- 
treated usually present, after the disease has run its course, a 
destruction of the membrana tympani over a greater or less 
area. 

The internal wall of the middle ear may be covered by a 
cicatrix extending from the margins of the opening in the 
tympanic membrane to the osseous wall of the middle ear, 
practically converting it into a closed cavity. In other in- 
stances where the membrana tympani has been almost com- 
pletely destroyed we find the internal wall presenting a pale, 
glazed appearance ; the parts are perfectly dry, and the mu- 
cous membrane has become changed to one which does not 
secrete moisture. Again, the internal wall of the tympanum 
may be somewhat thickened and moistened by its normal 
mucous secretion without any discharge appearing in the 
canal. The ossicular chain is usually bound down to the in- 
ternal tympanic wall at various points by cicatricial bands. 
The amount of interference with the function varies in differ- 
ent cases and depends upon the location of adhesions. 

In the majority of instances, in cases which have been un- 
treated during an acute attack, a chronic purulent otitis de- 
velops, and careful investigation will show areas of bony 
necrosis either in the walls of the tympanum or confined to 
the ossicular chain. The location of the perforation and its 
diagnostic significance in cases where the discharge persists 
will be more fully dwelt upon in the consideration of chronic 
purulent otitis media. 

Death may result from the disease, from direct involve- 
ment of the cranial contents, either directly or after the devel- 
opment of mastoid inflammation. This last complication is 
of common occurrence where the disease does not come un- 
der observation in the acute stage. The prognosis as to the 
integrity of function is rather better than might be expected 
when we consider the extensive loss of substance which the 
malady entails. Serious labyrinthine involvement is decid- 



344 ACUTE PURULENT OTITIS MEDIA. 

edly the exception, and when the labyrinth is involved the in- 
vasion is usually primary, dependent upon the same cause 
as has produced middle-ear inflammation, rather than as sec- 
ondary to the tympanic disease. 

Treatment. — Vigorous measures must be instituted in the 
earliest stages if we hope to abort the affection. When in 
the course of an acute infectious disease severe pain is com- 
plained of in the ear, and inspection reveals the character- 
istic congestion already mentioned, immediate local depletion 
should be instituted. As much blood as the general condi- 
tion of the patient will permit should be abstracted from the 
region in front of the tragus. The administration of an opi- 
ate to relieve pain is not advisable in these cases, since what- 
ever measures are to be instituted for the relief of the local 
condition must be employed in the course of a few hours, and 
it is unwise to mask any advance of the disease by blunting 
the susceptibility of the patient to the intensity of the pain. 
If local depletion does not produce immediate relief, the parts 
should be thoroughly incised. This operation is intensely 
painful, but quickly performed, and the wisdom of admin- 
istering a general anaesthetic must depend upon the general 
condition of the patient. The local application of cocaine to 
the region to be operated upon scarcely renders the proced- 
ure less painful, although it is wise to obtain whatever aid we 
may in this manner. The incision should lie above the short 
process of the malleus and posterior to it. The knife is en- 
tered just behind the processus brevis and carried upward 
and inward parallel to the neck of the malleus until it has 
pierced the cellular tissue within the tympanic vault and im- 
pinges upon the bony wall. The knife is then swept back- 
ward to the periphery of the membrane, the deep tissues 
being divided throughout the entire extent of the incision. 
If the long process of the incus is encountered, as may hap- 
pen if it lies high up in the cavity, or if the incision is carried 
a little too low, care must be taken not to displace it, the knife 
being allowed to glide over it, and afterward being pushed 
inward to the original depth to complete the incision. It is 
well, also, on reaching the periphery, to extend the section 
directly outward along the supero-posterior wall for a distance 
of a quarter of an inch, dividing all the soft parts down to 
the bone. Very free bleeding follows this operation, and the 
haemorrhage should be encouraged by irrigation of the canal 



TREATMENT— INCISION. 345 

with warm boiled water. It is to be distinctly understood 
that we do not expect to liberate pus by this procedure, but to 
prevent its formation. Consequently the greatest care must be 
taken that the field of operation is in an aseptic condition, and 
that all instruments and the fluid used subsequently in irrigat- 
ing the region are thoroughly aseptic. This measure, when 
performed sufficiently early, may completely abort the at- 
tack ; the divided tissues unite firmly at the end of a few 
days, and all symptoms referable to the ear may disappear 
completely. When seen at a later period, and when the parts 
are distinctly bulging, it is wise to vary the procedure to the 
extent of beginning the incision over the area of the greatest 
bulging, remembering that our object is to incise the vascu- 
lar tissues located in the superior portion of the cavity, and to 
liberate any contained fluid as well. Here, instead of carry- 
ing the incision outward upon the canal wall, the knife may 
be plunged directly into the most prominent portion of the 
tumor, carried deeply into the tympanic vault, and the parts 
divided directly upward as far as the superior margin of the 
meatus (Figs. 87 and 97); the peripheral attachment of the 
membrane posteriorly should then be followed downward for 
a short distance, thus forming a triangular flap, to favor free 
drainage. When spontaneous perforation has taken place we 
usually find it necessary to enlarge the opening. This meas- 
ure should be carried out according to the rule which gov- 
erns the primary incision. 

Upon the appearance of discharge after spontaneous rup- 
ture, or after surgical interference, the canal must be kept as 
free as possible by frequent irrigation with a warm antiseptic 
solution. This not only tends to relieve pain by depleting 
the tissues, but is of the greatest importance in preventing a 
localized infection of the canal. The development of a fu- 
runcle during the course of the disease is to be especially 
avoided, as it may mask an involvement of the mastoid pro- 
cess, or may be mistaken for this condition. A localized tu- 
mefaction of the canal indicative of mastoid involvement is 
situated at the fundus, upon the postero-superior wall of the 
meatus, and close to the drum membrane (Fig. 78). In this 
region the development of a primary infectious process in the 
canal wall is exceedingly rare, circumscribed otitis externa 
usually occurring in the fibro-cartilaginous portion. Tender- 
ness upon deep pressure over the mastoid, care being taken 



346 ACUTE PURULENT OTITIS MEDIA. 

not to communicate any motion to the movable part of the 
canal during- the examination, will also aid us in deciding 
that the mastoid is involved, while tenderness on pressure 
about the ear, which imparts a certain amount of motion to 
the fibro-cartilaginous portion of the meatus, or on traction 
upon the auricle, will point to a circumscribed external otitis 
of a simple character. 

When the symptoms point to mastoid involvement, great 
caution is necessary in order that measures may be undertaken 
at a sufficiently early period to prevent this complication. 
With the accession of any tenderness over the mastoid region, 
either directly over the antrum or at the apex, the Leiter coil 
or aural ice bag should be immediately applied and kept in 
position continuously for a period of at least thirty-six hours. 
In addition to this, attention should be given to the primae viae. 
The diet should be light, and any tendency to constipation 
should be overcome by the free use of saline cathartics. Any 
tumefaction of the tissues at the upper and posterior part of 
the bony meatus close to the drum membrane should be im- 
mediately incised, since the relief of tension here, in conjunc- 
tion with cold externally and frequent irrigation of the canal, 
will usually abort the attack. Here, again, it is not advisable 
to administer drugs for the purpose of relieving pain, or cer- 
tainly not for any long period. If the pain in the mastoid 
region remains moderate for twenty-four hours, and manipu- 
lation elicits an increase in the amount of tenderness, it may 
be wise to insure a fair amount of sleep for one night by 
the administration of morphine. This plan should not be 
repeated, for if on the following day no marked amelioration 
of the symptoms is present, operative measures directed to 
the mastoid process should be at once instituted. I can hardly 
speak favorably of local bloodletting over the mastoid region. 
Occasionally it may be followed by relief ; but my experience 
has been that, where blood has been abstracted from this re- 
gion, the symptoms have been delayed only, but the complica- 
tion has not been prevented. Another objection to local blood- 
letting lies in the fact that the tenderness of the parts to which 
the measure gives rise may mask that due to the inflammation 
of the osseous structures. This is not a serious objection, to 
be sure, and a little care on the part of the surgeon will enable 
him to distinguish between superficial and deep tenderness. 
At the same time it is important for us to recognize the fact 



TREATMENT— MASTOID INVOLVEMENT. 



347 



of mastoid involvement as soon as it takes place, and not delay 
prompt interference. Any measures which temporarily re- 
lieve the symptoms, or cause the disease to progress more 
slowly, are of decided disadvantage, and often a menace to 
life. The particular operative measures to be adopted when 
the mastoid is involved will be fully described in the section 
devoted to surgery. It should be stated here, however, that 
the author is decidedly averse to the employment of a sim- 
ple incision over the mastoid in these cases. The value of 
the so-called "Wilde's incision" depends upon the depletion 
and a certain amount of relief to tension secured by division 
of the periosteum. The operation is exceedingly painful, and 
a general anaesthetic is usually necessary. In all cases where 
the Wilde incision is positively demanded it will probably be 
necessary to enter the mastoid at a later period, and to give 
the patient an anaesthetic upon one day, for the purpose of 
making a superficial incision, and to repeat it a day later, 
for the purpose of completing the operation and enter- 
ing the mastoid process itself, is absolutely unjustifiable. 
When, therefore, external incision seems indicated, but the 
surgeon does not feel justified in entering the bone, it is much 
better to wait for twenty-four or forty-eight hours, at which 
time no doubt will exist as to the proper course to pursue. 
Incision within the canal has already been spoken of, and is 
in reality an internal Wilde's incision. The pneumatic cells 
of the mastoid are located much nearer the superior wall of 
the meatus than to the external surface of the mastoid cortex. 
This incision in the canal frequently relieves tension suffi- 
ciently to prevent an extension of the inflammation. When- 
ever internal incision will not relieve the condition within the 
mastoid, external incision certainly will not, and in adults it 
should be a cardinal rule never to depend upon the operative 
measure of dividing the soft parts alone. In children under 
three years of age, where the mastoid cortex is thin and the 
cells may be opened with a stout scalpel, the procedure may 
occasionally be justifiable ; but even here experience has 
taught me that a complete operation under general anaesthesia 
is better than to incise the superficial structures simply and 
secure imperfect drainage. The opening must be small, and 
no knowledge of the extent of the tissue involved can be 
gained, while the exit to the discharge can not be free. 
Therefore, whenever any operative procedure is instituted 



348 ACUTE PURULENT OTITIS MEDIA. 

upon the mastoid it should be thorough, and should be per- 
formed under general anaesthesia. 

We occasionally meet with cases which, after incision of 
the membrana tympani and the establishment of drainage, 
progress favorably for a certain period, after which — proba- 
bly because of a fresh access of inflammation — the discharge 
increases in amount, the pain returns, and the symptoms are 
repeated, although not to the same degree. Here it is neces- 
sary to re-incise the drum membrane and thoroughly evacuate 
the contents of the tympanic cavity. Each recurrence incurs 
the danger of mastoid inflammation, and to delay the estab- 
lishment of free drainage through the external meatus, in the 
hope that the inflammatory process may disappear spontane- 
ously, is certainly unwise. If the parts are kept thoroughly 
cleansed and attention is paid to the proper exit of the dis- 
charge, very little local treatment is necessary aside from this. 
Occasionally, owing to the impoverished general condition 
of the patient, or to some obstructive lesion in the upper air 
passage, especially to enlargement of the pharyngeal tonsil in 
children, the discharge becomes small in amount and assumes 
a watery character, but does not cease completely. Here 
attention to the general health is of prime importance, since 
if the discharge is allowed to continue too long the ossicles 
are apt to become involved, and a chronic purulent otitis may 
be established. If the pharyngeal vault is the seat of adenoid 
vegetations, these should be removed. 

In case the discharge does not cease as promptly as might 
be expected, owing to inattention on the part of the patient 
regarding thorough cleansing of the canal, granulation tissue 
may develop along the margins of the incision or spon- 
taneous perforation in the membrana tympani, or the mucous 
membrane within the tympanic cavity may become greatly 
hypertrophied and protrude through the perforation in the 
form of a pedunculated mass, constituting an aural polyp, 
so called. This obstructs the free outflow of the secretion, 
and must be either removed or destroyed in situ. Removal 
may be easily effected by means of a delicate snare armed 
with fine wire. For destroying these exuberant granulations 
either chromic acid or the fused bead of nitrate of silver may 
be used. Care should be taken to thoroughly dry the granu- 
lations before the escharotic is applied -and to make the ap- 
plication to the hypertrophied tissue only, and not allow it to 



TREATMENT— DRAINAGE. 



349 



spread to the surrounding parts. This is effected by lightly 
touching the parts which have been cauterized with a pledget 
of dry cotton immediately after cauterization, to remove any 
excess of the agent employed. If delicately executed, the 
procedure is not painful, but it is always wise to anaesthe- 
tize the part with a ten-per-cent solution of cocaine, previous 
to cauterization. Chromic acid, I think, is the safer agent to 
employ, as nitrate of silver is sometimes followed by a rather 
sharp reaction. 

Again, the hypertrophied covering of the internal tym- 
panic wall, instead of assuming a distinctly polypoid appear- 
ance, may present as a diffuse thickened membrane. This 
occurs especially when the perforation is of large size, expos- 
ing the tympanum over a considerable area. Here we make 
use of the metallic astringent salts in aqueous solution, nitrate 
of silver being the favorite, although sulphate of copper, sul- 
phate of zinc, chloride of zinc, or the persulphate of iron 
may be employed probably with equally good results. The 
strength of the solution used must vary with the special con- 
dition of the parts. It is always well to test the susceptibility 
of the patient by beginning with weak solutions and to in- 
crease the strength according to indications. The silver solu- 
tions may be used in strengths of from two to fifty per cent ; 
the zinc salts in strengths of from two to four per cent. If 
sulphate of copper is employed the degree of concentration 
should not exceed ten or fifteen grains to the ounce. 

The persulphate of iron seems to be of particular value in 
causing a rapid disappearance of granulations developed about 
the. margins of a perforation. The solution may be used full 
strength or diluted with water, according to the size and 
character of the granulations. The patient should be seen 
the day following such applications, as occasionally the re- 
action will cause closure of the opening in the drum mem- 
brane, and symptoms dependent upon pus retention may su- 
pervene. 

When only a small quantity of discharge remains we may 
find that the use of fluid in the canal increases rather than 
diminishes the amount of discharge. If the case is watched 
closely, astringent or antiseptic powders may be employed, 
care being taken that the opening in the membrana tympani 
is not occluded, the powder being insufflated so as to form 
a thin covering over the membrana and the canal walls. If 



350 ACUTE PURULENT OTITIS MEDIA. 

this plan is adopted the patient must be seen daily by the 
surgeon and the parts thoroughly cleansed by means of the 
cotton pledget, after which the powder is lightly dusted over 
the membrana tympani, the granulations, or the exposed wall 
of the middle ear, as the case may be. We may use boric 
acid, iodoform, iodol, or dermatol. When the walls of the 
canal appear sodden from long-continued irrigation, the addi- 
tion of a small amount of oxide of zinc to any of the above 
powders is desirable. This protects the denuded lining of the 
meatus and favors the formation of normal epithelium. After 
the opening in the drum membrane is closed, inflation should 
be employed at first daily, the interval being increased as the 
parts resume their normal appearance. It is important that 
this plan should be carried out; otherwise adhesions may 
develop in the tympanum and the function of the organ be 
decidedly impaired. 



CHAPTER XXI. 

CHRONIC CATARRHAL OTITIS MEDIA. 

Under chronic catarrh of the middle ear various affections 
of the tympanum have been described. The selection of this 
name is particularly unfortunate, since it conveys the impres- 
sion that the disease is really a complicating- lesion of some 
condition in the nose or naso-pharynx. " Catarrhal deafness " 
is a term which appears not only in our standard works upon 
otology, but also forms a prominent feature of the advertise- 
ment of almost every charlatan. 

In the first place, catarrh as a disease does not exist, it 
being merely a term used to describe a symptom, meaning 
from its derivation simply a discharge. By common consent 
catarrhal inflammation is the term applied to a simple inflam- 
mation of any mucous membrane. It may occur in the ear 
or elsewhere, constituting a primary disease entirely inde- 
pendent of any lesion in the upper air passages. 

When the mucous membrane of the middle ear is the seat 
of such a chronic inflammatory process the changes which 
take place are of two varieties : In one form, which may be 
termed a hypertrophic inflammation, we have a swelling of 
the lining membrane of the tympanum, due usually at first 
to a chronic venous congestion ; this continuing for a long 
period results in hypertrophy of the elements of the tissue 
lining the cavity. Over the bony internal wall of the mid- 
dle ear the mucous membrane is thickened and hyperaemic 
and the glandular elements produce, therefore, an excessive 
amount of secretion. In the drum membrane the same pro- 
cess takes place ; the fibrous layer becomes thickened in 
places, and may over certain areas be the seat of calcareous 
deposits. The same changes take place in the ossicles, liga- 
ments, and in the walls of the Eustachian tube. Owing to 
the chronic hyperaemia, serum or sero-mucus may collect in 
the cavity and remain there permanently, or the fluid may dis- 
appear from time to time when the congestion is less marked. 

(351) 



352 CHRONIC CATARRHAL OTITIS MEDIA. 

In contradistinction to these changes, we find in another 
class of cases a process characterized by tissue hyperplasia 
rather than by hypertrophy ; the new tissue is firm and fibrous 
in character, secretion is diminished, the walls of the ves- 
sels supplying the parts are thickened, and a true sclerosis 
results. In this form of inflammation the favorite site of the 
inflammatory process is the region of the oval and round win- 
dows. The outer wall of the tympanum — that is, the mem- 
brana tympani — may present almost no variation from the nor- 
mal appearance. In the Eustachian tube the tissue changes 
cause an actual increase in the calibre of the canal as the mem- 
brane becomes firmer and more closely applied to the parts 
beneath. In the tympanic ligaments this sclerotic process in- 
creases their firmness, binding the ossicles rigidly together 
and fixing them firmly within the cavity, so that the degree 
of motion in every direction is much reduced. About the sta- 
pedial niche we find dense connective-tissue bands running 
from the head of the stapes and from the crura to the walls 
of the pelvis ovalis. The motion of this ossicle is therefore 
greatly limited. At the round window similar changes pre- 
vent, the compensatory movements of the membrana tympani 
seco-ndaria and render the vibratory motion of the labyrin- 
thine fluid difficult or impossible. Whether the hyperplastic 
form of inflammation is often secondary to the hypertrophic 
form is a mooted question, but the weight of evidence seems 
to favor this view. 

Chronic Hypertrophic Otitis Media. 

etiology. — A chronic hypertrophic inflammation within 
the tympanum may follow an acute catarrhal otitis, an acute 
congestion of the Eustachian tube which has failed to resolve 
completely, or a similar process in which the middle ear and 
tube are both involved. It may also occur as an idiopathic 
affection, the organ never having been the seat of an acute in- 
flammation. In any case where the disease is chronic from 
the beginning it depends upon some fault in the manner of life 
of the patient through which he becomes particularly suscep- 
tible to vascular changes in those portions of the body lined 
with mucous membrane. Frequent exposure to cold result- 
ing in repeated attacks of acute rhinitis or acute naso-pharyn- 
gitis, from which the vessels within the tympanum are fre- 
quently engorged with blood, is a most common cause. The 



/ETIOLOGY. 



353 



condition may begin in early life from the presence of a mod- 
erate amount of adenoid tissue in the pharyngeal vault, not 
enough to give rise to symptoms of nasal obstruction, but suf- 
ficient to cause a venous engorgement of its parts with each 
exposure to cold. This condition interferes with the intra- 
tympanic circulation, and, although the pharyngeal tissue may 
become entirely normal in later life, the changes set up within 
the middle ear may persist and even increase although the 
cause of the affection has disappeared. The disease is more 
commonly met with in individuals whose occupation renders 
exposure to inclement weather a matter of necessity ; it is 
hence more common in males than in females. No period of 
life is exempt from the disease, but it occurs more frequently 
between the ages of fifteen and thirty-five than before or after 
this period. Marked impairment of the general health, either 
from a severe illness, from prolonged mental anxiety, or from 
privation, constitutes a factor in the causation of many cases. 
The abuse of alcohol also exerts a certain effect in the pro- 
duction of the disease, both from its local action upon the di- 
gestive organs and its influence upon the circulatory system. 
We are often told that the aural lesion is due to the extension 
of inflammation from the pharyngeal vault because of the con- 
tinuity of anatomical structure. While this may be so, it is 
certainly a question of little importance, since the same causes 
acting to produce the pharyngeal inflammation may exert 
their effect primarily upon the lining membrane of the tym- 
panum. The excessive use of tobacco is not responsible for 
the disease under consideration, except as it may affect the 
general health ; the inhalation of smoke produces quite as 
deleterious an effect upon the respirator} 7 organs and middle 
ear from local action as does the actual use of the weed. 

The opinion so prevalent, that impaired hearing due to 
catarrhal inflammation of the tympanum is to a certain extent 
hereditary, is not entirely borne out by experience. A care- 
ful examination of statistics shows that in the disease under 
consideration heredity plays a very unimportant part in the 
causation. It is true that certain families seem to show a 
particular predisposition to inflammations of the lymphatic 
type, engorgement of the lymph nodules occurring with any 
slight local inflammation. This is seen if we observe the fre- 
quency with which adenoid vegetations are observed in dif- 
ferent members of the same family through several genera- 
24 



354 



CHRONIC CATARRHAL OTITIS MEDIA. 



tions. Since these growths exert an influence upon tympanic 
conditions, it is not strange that the belief should be held that 
the aural affection is transmitted from one generation to an- 
other. In many cases, however, we find the pharyngeal lym- 
phatics enlarged through several generations without any 
aural affection. It is probable, therefore, that the influence 
of heredity is limited to the lymphatic deposits, which render 
the ears more easily affected by slight changes. It is seldom 
that any hereditary history of the aural disease is met with 
without the accompanying lymphatic taint. 

Pathology. — The pathological changes have been described 
somewhat at length in the introductory remarks. To recapit- 
ulate, they consist in a swelling of the lining membrane of the 
tympanum, due at first to a venous congestion, but afterward 
to an actual tissue hypertrophy. The newly formed tissue 
is vascular and richly supplied with cellular elements, the 
fibrous elements being but little developed. An actual in- 
crease in volume is the result of this process, and is charac- 
teristic of this form of inflammation. The presence within 
the tympanum of a fluid exudation, due either to an abnor- 
mal activity of the secretory glands or to the transudation of 
the fluid elements of the blood from the engorged vessels, 
constitutes another prominent feature. No particular por- 
tion of the middle ear is involved by preference, even the 
membrana tympani sharing in the changes wrought by the 
morbid process. In the membrana tympani there is thicken- 
ing of the mucosa and swelling of the fibrous layer, followed 
by true hypertrophy here, and in the advanced stages by a 
deposit of the lime salts. 

As involving the drum membrane, the structural changes 
produced are usually more marked in some parts of the mem- 
brana tympani than in others. This results in an irregularity 
of texture, some portions appearing dense and opaque, while 
others, by contrast, appear thinner than normal (see colored 
plates). In the Eustachian tube the tissue changes within 
the walls narrow its lumen, and prevent the entrance of air 
into the middle ear. This reduces the tension within the 
middle ear, and causes depression of the membrana tympani 
from atmospheric pressure. A gradual stretching of the drum 
membrane takes place from the continued pressure from with- 
out, until finally further displacement is prevented by contact 
with the internal tympanic wall. The pressure against this 



PATHOLOGY. 



355 



resisting barrier increases the local inflammatory process. 
The movement of the drum membrane inward and its per- 
sistence in this position is favored by the action of the tensor 
tympanic muscle, which by contraction draws the membrane 
inward against the wall of the middle ear. From disuse the 
tendon becomes shortened, this change being aided by the 
inflammatory process. If now the Eustachian tube is re- 
stored to its normal patency, the membrana tympani does 
not assume its correct position, and it may even be impossible 
to replace it by artificial means. Similar changes occur in 
the intratympanic ligaments if the parts are suffered to re- 
main misplaced for a considerable length of time. Of the 
ligaments which bind the ossicular chain together the cap- 
sular ligament of the malleo-incudal articulation suffers the 
most. It may become relaxed, and render displacement of 
the ossicular chain more easy. From the relaxation of this 
ligament the entire drum membrane and the tip of the handle 
of the malleus may be carried directly inward toward the 
tympanic wall by rotation of the malleus upon the axis band. 
The separation of the articular surfaces of the malleus and 
incus prevents the perfect transmission of the aerial vibra- 
tions to the stapes, and impairment of function results. 

When the hypertrophic process changes to the hyper- 
plastic variety the newly deposited connective tissue be- 
comes transformed, its cellular elements disappear, and are 
replaced by a dense fibrous tissue, which by contraction in- 
creases the tension in the ossicular chain. 

As to changes occurring in the labyrinth from the process 
within the middle ear, these may depend upon the pressure 
to which the labyrinthine fluid is subjected from the increased 
tension, although this factor exists in the early stages only. 
Labyrinthine complications are not common in the hyper- 
trophic form. The most prominent element in their causa- 
tion is the interference with the labyrinthine circulation. Al- 
though the communication between the t} 7 mpanic and laby- 
rinthine vessels is not intimate, hypertrophic changes within 
the middle ear exert an influence probably upon the parts 
from which they are separated only by the thin membrane of 
the round window and by the fibres of the annular ligament 
in the fenestra ovalis. A large portion of the venous blood 
from the labyrinth enters the general circulation through 
the vena aquseductus cochleae, which leaves the labyrinth 



356 CHRONIC CATARRHAL OTITIS MEDIA. 

close to the round window. Hence any increased vascular- 
ity within the tympanum affects the venous flow through this 
channel both by mechanical pressure and by the change in 
the rapidity of the flow of the blood current. The actual 
communication between the vessels of the middle ear and the 
labyrinth has been demonstrated by Cassebohm,* the anas- 
tomosis taking place at the round window. Buck has dem- 
onstrated a similar communication at the oval window. The 
perforating vessels, which Politzer claims to exist, have al- 
ready been mentioned. While, therefore, the communication 
may not be very direct, a disturbance of the circulation 
within the middle ear, if continued for a long period, must 
cause changes in the labyrinthine blood current, and corre- 
sponding changes in labyrinthine pressure. 

Symptomatology. — The affection is usually bilateral, al- 
though both organs are seldom involved to the same degree. 
The hearing with which we are endowed is far in excess of 
that necessary to carry on the ordinary vocations of life, and 
one may be unconscious of any impairment of function until 
it exists to a marked degree. When these patients come un- 
der observation they seek relief either on account of the im- 
pairment in function or because of distressing subjective noises. 
The impairment of function is usually intermittent in the early 
stages, the periods during which the hearing seems to the 
patients to be fairly normal having become gradually shorter 
and shorter, until at last they seek relief. This irregularity 
in the occurrence of the symptoms is quite characteristic of 
the hypertrophic variety of inflammation of the middle ear. 
Sudden changes in temperature, indiscretions in diet, or im- 
pairment of the general health cause the local symptoms to 
increase in severity on account of the changes which they 
effect in the mucous membrane. The subjective noises are 
usually more pronounced upon one side than upon the other, 
and the same is true of the impairment in hearing. These 
symptoms may be more marked in the same ear, although 
where the disease has existed for a long time we may find 
that the noises have entirely disappeared from the ear first 
affected, tinnitus being distressing only upon the opposite 
side. Changes in the position of the body may influence both 
the character and the degree of the subjective noises. Quite 

* Cited by Urbantschitsch, Lehr. der Ohrenheilk., Vienna, 1891, p. 235. 



SYMPTOMATOLOGY. 



357 



frequently they are only noticed when the patient is lying 
down. They may be synchronous with the cardiac pulsa- 
tions, or may be continuous. They are usually high-pitched, 
and are variously described as singing, hissing, blowing, or 
whistling sounds. These subjective noises may be entirely 
drowned by external sounds. Thus they may disappear in a 
railway train or on a busy thoroughfare, but reappear instant- 
ly in a quiet room. In the same way external noises affect 
the hearing to a marked degree. Most of these patients are 
able to hear better in a noise than where it is quiet. We may 
explain this fact either upon the hypothesis that the more in- 
tense sounds serve to set the ossicular chain in vibration, 
after which sounds of less intensity are able to so modify 
this motion as to be perceived, although they are unable to 
overcome intratympanic rigidity by themselves, or that loud 
sounds produce a condition of auditory hyperesthesia. 

Where fluid is present in the middle ear, bubbling sounds 
may be complained of upon forcible attempts at clearing the 
nostrils. Snapping or cracking sounds heard in the ear with 
each act of deglutition, due either to the separation of the 
walls of the Eustachian tube at this moment or to the entrance 
of air into the tympanum, is also a symptom often met with. 
Occasionally we may elicit the fact that upon changing the 
position of the head the hearing becomes suddenly impaired. 
This is frequently due to the presence of fluid within the 
tympanic cavity, the change in position causing it to gravitate 
to the region of the oval and round windows, and thus to im- 
pede the vibration of the labyrinthine fluid. Occasionally 
slight vertigo is complained of. This, however, is not severe, 
and is usually attributable to a sudden change in intratym- 
panic pressure, as by auto-inflation, in the act of blowing the 
nose, aspiration of the tympanum by a sudden deep inspira- 
tion, etc. 

Pain is not common in these cases, although, when a sud- 
den stenosis of the tube occurs, the patient may complain of 
occasional neuralgic pains radiating from the pharynx in the 
direction of the ear. In certain rare instances, where the 
chronic inflammation is confined mostly to the region of the 
Eustachian tube, the patient may complain of sharp pain in 
the throat, referred to the region of the lingual tonsil, fre- 
quently more severe upon one side. It is impossible for the 
patient to locate the exact painful point, although frequently 



358 CHRONIC CATARRHAL OTITIS MEDIA. 

it is referred to the posterior pharyngeal folds or to the lymph 
tissue at the base of the tongue. In a large number of these 
cases the pharynx is entirely healthy, and the pain is due to 
the changes in the Eustachian tube. The true nature of the 
affection is frequently discovered accidentally, or not until 
changes within the tympanum have become so marked as to 
demand measures for relief. Most frequently the patient de- 
scribes the sensation as not amounting to actual pain, but that 
the throat feels " rough " or " burns." In other cases the pain 
is intense, rendering deglutition difficult. 

Diagnosis. — A. Physical Examination. — The appearance 
presented by the parts varies according to the extent to which 
the process has advanced. In the early stages, upon inspecting 
the drum membrane, there may be no deviation from the nor- 
mal picture. The most frequent change is a moderate de- 
gree of depression of the membrana tympani, evidenced by 
a foreshortening of the manubrium mallei and exaggeration 
of the posterior fold (Fig. 103). The color of the membrane 
is either normal, or there may be a slight reddening along 
the malleus handle and at the supero-posterior border of the 
membrane, together with a reddish reflex from the internal 
tympanic wall. This last sign is considered particularly im- 
portant by Schwartze, as indicative of the fact that the inflam- 
matory process is still active. The lustre of the membrane is 
usually slightly diminished, while in texture it appears some- 
what thicker than normal. This apparent increase in density 
is usually not general, but is more prominent over certain 
areas. An appearance which is quite characteristic of the 
early stages is the rotation of the malleus 
upon its long axis, which, if the membrane 
is at the same time retracted, causes the 
malleus handle to appear narrower than nor- 
mal. If there is no depression, the rotation 
may cause the manubrium to appear abnor- 
Fig 102 -Rotation ma]1 wide / Fi IQ2 y This c hange in breadth 

of malleus about # J .... . 

its long axis in- is due to inequalities in tension of the intra- 
:rSanu e brium h tympanic ligaments from the inflammatory 
process, which is more pronounced in cer- 
tain portions of the cavity than elsewhere. The presence 
of adhesions or the irregular tumefaction of the membrane 
prevents displacement of the ossicular chain by rotation of the 
malleus about the axis band, but acts in such a manner as to 




DIAGNOSIS— PHYSICAL EXAMINATION. 359 

twist the ossicle about its long axis, turning one of its pris- 
matic surfaces toward the canal. When displacement inward 
and rotation are both present, a sharp edge of the shaft 
of the malleus is presented to the meatus, thus making the 
shaft appear narrow. The short process is usually more 
prominent and whiter than normal. The position which it 
assumes gives important information as to the direction in 
which rotation has taken place, and whether the increased 
tension lies in the anterior or posterior half of the tympanum. 
The upper portion of the membrane above the short process 
frequently has a crumpled appearance due to localized areas 
of inflammation in the parts beneath. When the disease 
has existed for some time the membrane in this region may 
appear abnormally thin, and over the neck of the malleus may 
be adherent and much depressed. Pressure here may cause 
atrophy of the fibrous tissue, and may give the membrane the 
appearance of having been perforated and having undergone 
cicatrization. In the more advanced cases we find the mem- 
brana vibrans displaced toward the prom- 
ontory, the tip of the malleus frequently 
impinging upon the wall of the middle ear. 
It may be drawn either toward the anterior 
or posterior wall of the tympanum, accord- 
ing to the distribution of the connective 
tissue within the cavity. When displaced fig. 103.— Retraction 
backward and inward, we frequently see a ° f the drum mem - 

^ J brane and adhesions 

tense band running from the short process within the middle 
downward and backward until it is lost -^J* "^ 
in the posterior margin of the membrane and the supemumer- 
(Fig. 103); so well defined is this that it is distinct. 6 "** 
frequently mistaken for the handle of the 
malleus, which lies in front of it, and is only visible when the 
head of the patient is turned so as to permit the light to be 
directed beneath this fold. Pomeroy has given the name of 
" supernumerary posterior fold " to this band. 

When there is fluid within the tympanum the membrana 
tympani is apparently crossed by a fine line, which marks the 
level of the fluid. This appearance is only presented when 
the drum membrane is not thickened from hypertrophic 
changes. If this has taken place, the level of the effusion 
can not be made out, but the segment below the level of 
the fluid appears more opaque than the part above. The 




360 CHRONIC CATARRHAL OTITIS MEDIA. 

drum membrane over the transudate is of a yellowish tinge, 
the appearance being more marked if the secretion is inspis- 
sated. Occasionally fine bubbles may be seen, appearing as 
distinct bright points upon the membrana. Any of the above 
appearances should make us suspect the presence of fluid, and 
any alteration in the picture after inflation confirms the opin- 
ion. If the membrana tympani has remained in contact with 
the internal wall of the middle ear for a considerable length 
of time, the pressure may have caused partial absorption of 
the fibrous layer, increasing the transparency of the mem- 
brane in this locality. On the other hand, areas which pre- 
sent evidence of a hypertrophic process are frequently the 
seat of calcific deposits in the later stages of the disease. The 
development of adhesions between the membrana vibrans and 
internal wall of the middle ear is scarcely as characteristic of 
the hypertrophic variety of the inflammation as of the hyper- 
plastic, yet we may find this condition present, especially in 
the region of the umbo, as this is the first point of contact be- 
tween the drum membrane and the external tympanic wall, 
the displacement being due both to atmospheric pressure and 
to the action of the tensor tympanic muscle. 

In certain cases, especially where frequent auto-inflation 
has been practiced, the drum membrane becomes much re- 
laxed in the upper and posterior quadrant, and when indrawn 
applies itself so closely to the bony walls as to permit the intra- 
tympanic landmarks in this region, such as the incudo-stapedial 
articulation and the niche of the round window, to be clearly 
made out (Fig. 95). Such a relaxation of the membrana is 
easily demonstrated if we request the patient to inflate the 
ear by holding the nose, closing the mouth, and blowing 
forcibly. When this is done the upper and posterior seg- 
ment will be seen to move outward into the canal, while at 
the same time the deeper parts disappear from view. 

The impairment of hearing in these cases disappears to 
an astonishing extent when this relaxation is corrected, but 
may reappear upon deglutition, the air within the middle ear 
being aspirated and the membrane assuming its former posi- 
tion. The presence of adhesions or the condition of relaxa- 
tion just described may be satisfactorily demonstrated by 
alternately rarefying and condensing the air in the meatus by 
means of the pneumatic otoscope. The adherent areas do 
not move, while the relaxed portions of the drum membrane 



DIAGNOSIS— PHYSICAL EXAMINATION. 361 

are seen to make exaggerated inward and outward excursions, 
according as the air within the canal is condensed or rarefied. 

Anomalies in tension of the intratympanic ligaments are 
easily demonstrated by the pneumatic otoscope. Under ma- 
nipulation the malleus handle, instead of moving directly out- 
ward when the air within the canal is rarefied, will be seen to 
twist upon its long axis, the tip of the manubrium frequently 
remaining fixed, while the short process describes the arc of 
a circle. Clinically this sign is of importance, as it usually 
indicates relaxation at the malleo-incudal articulation, and 
may account for certain subjective symptoms which make 
their appearance only when the patient changes his position 
and suddenly separates the articular surfaces of these ossicles. 

Inflation by the catheter or air bag — preferably the former 
— elicits various auscultatory signs. Evidences of fluid within 
the tympanum have already been mentioned and need not be 
repeated. When the lumen of the tube is narrowed, the air, 
upon entering the middle ear, will produce a high-pitched 
sound on account of the narrowing of the canal. This sound 
may be either moist or dry, according to the stage of the dis- 
ease. When the tube is much narrowed and the walls are 
covered with thick secretion, the air may fail to enter the 
middle ear, and a distinct percussion sound will be recognized 
with each attempt at inflation, as the air impinges upon the 
mass of inspissated mucus at the narrow portion of the tube. 
Prolonged effort will usually dislodge this, after which the 
air will enter the cavity, causing a sudden outward excursion 
of the drum membrane, as evidenced by the peculiar sharp 
click heard as it is driven outward. If the cavity is com- 
pletely filled with fluid, absolutely no sound may be heard. 
It is possible for the adhesions to develop in such a manner 
as to shut off the greater part of the tympanic cavity from 
the Eustachian tube. When this occurs, the air, as it im- 
pinges upon the barrier at the tympanic orifice, will produce 
a distinct percussion note similar to that heard when an ob- 
struction is present at the isthmus of the tube, but not as re- 
mote. Marked relaxation of the drum membrane is recog- 
nized by the peculiar flapping sound which is heard as the lax 
septum is forced outward. 

Inspection of the membrane immediately after inflation 
will enable us to determine over what areas adhesion has 
taken place between the internal and external tympanic walls. 



362 CHRONIC CATARRHAL OTITIS MEDIA. 

As before stated, adhesion at the umbo is not uncommon, and 
hence inflation may produce little change in the position of 
the membrane, although the hearing may be greatly improved 
by the operation from the re-establishment of equilibrium. 

B. Functional Examination. — The hearing power for the 
voice is considerably reduced. The hearing power for the 
watch or acoumeter is also diminished. The lower tone limit 
is elevated, and where the middle ear alone is involved the de- 
gree of elevation corresponds to the impairment of audition 
for the whisper or for the conversational voice. These cases 
usually hear a whisper relatively better than articulate speech. 
This is due to the fact that the pitch of the whisper of any 
given combination of letters is always the same, while in ar- 
ticulate speech the same word or sentence repeated by differ- 
ent individuals varies greatly, owing to the presence of over- 
tones. The individual quality of the voice depends upon 
these overtones. Hence we find the power of perception for 
the conversational voice varies greatly according to the indi- 
vidual with whom the patient converses, with some the hear- 
ing being but slightly diminished, while with others marked 
impairment is evident. The upper tone limit is either nor- 
mal or slightly lowered. Bone conduction is increased in the 
early stages of the disease, the vibrating tuning fork, placed 
in the median line, being referred to the poorer ear. In ad- 
vanced cases it may be referred to the better ear, and when 
this is the case. the prognosis is less favorable. Where the 
upper tone limit is lowered it not infrequently happens that 
the greatest deviation from the normal standard is in the bet- 
ter ear. This is explained upon the theory that the increased 
labyrinthine pressure upon the side first affected has caused 
certain changes to take place in the cortical area specialized 
for the perception of these particular notes. This area re- 
ceives most of its nerve fibres from the ear of the opposite 
side, but a few come from the organ of the same side. The 
influence of the tympanic condition upon the labyrinth of the 
organ first attacked institutes certain cortical changes which 
affect secondarily the nerve fibres derived from the other ear. 
These secondary changes expended upon the receptive mech- 
anism are more rapid than the changes within the middle ear; 
and we find the labyrinthine degeneration on the side last 
involved more marked than in the organ primarily affected. 
It is of importance to recognize this fact as indicative of the 



PROGNOSIS. 363 

progress of the disease, and prompt measures must be insti- 
tuted to curtail the steady advance of the affection. 

Prognosis. — The ultimate outcome will depend upon the 
cause, the social condition of the patient, and the extent to 
which the process has advanced before the patient comes 
under observation. 

When seen in the early stages associated with affections 
either of the nasal passages or of the naso-pharynx, we may 
hope to arrest the disease completely, and in a large measure 
to correct the damage already done. The station in life oc- 
cupied by the patient influences the progress of the disease, 
in so far as it necessitates his exposure to inclement weather, 
physical hardship, sudden changes of heat and cold, and pro- 
longed mental exertion. The age of the patient is also a fac- 
tor. Thus, if the impairment of function is considerable in a 
patient under thirty years of age, we can scarcely hope for 
great improvement except by the employment of the most 
radical means at our command; while the same degree of im- 
pairment met with later in life would be more amenable to 
treatment, since at this period hypertrophic changes in the 
upper air passages are the exception, the tendency being for 
spontaneous absorption to take place, and the affection might 
even improve spontaneously. In any given case where the 
aural lesion is associated with some affection of the upper air 
passages, we can usually promise, by restoring these parts to 
their normal state, to relieve the patient of those sudden fluc- 
tuations in hearing dependent upon vascular disturbances in 
the upper air passages. At the same time the progress of the 
disease will probably be checked, but any marked improve- 
ment in hearing can not be promised if the patient is more 
than thirty years of age, although in many instances the re- 
sults of treatment are exceedingly satisfactory. In young sub- 
jects the changes wrought by thoroughly freeing the upper 
air passages may cause a retrograde process to take place in 
the mucous membrane of the tympanum, and great improve- 
ment may result. The surgeon must be cautious, however, 
regarding the extent of improvement promised. 

Hygienic measures, the observance of which renders the 
patient less liable to colds, must'also be considered. In cases 
of long standing the prognosis will depend largely upon the 
presence or extent of secondary labyrinthine involvement, and 
particularly upon the degree to which the ear of the opposite 



364 CHRONIC CATARRHAL OTITIS MEDIA. 

side is affected. Any tendency toward secondary sclerotic 
changes as evidenced by patency of the Eustachian tube, or 
a degree of patency which is abnormal, will also render the 
prognosis more grave. The condition of the tube itself is of 
importance, as it enables us to judge of the changes which 
have probably taken place in tympanic adhesions. If the 
tube is of normal calibre it is probable that these have be- 
come firm, and that the impairment in function depends upon 
this cause. We can scarcely hope to absorb a deposit of long 
standing, and hence our prognosis must be guarded. 

Treatment. — We may divide this into the treatment of 
the upper air passages, the treatment of the Eustachian tube, 
and the treatment of the intratympanic condition. 

Our first care should be to place the upper air passages in 
such a condition as to permit free nasal respiration, and to pre- 
vent as much as possible the venous engorgement of these 
parts from slight exposure to cold. From this we do not 
mean that slight deviation from an ideal condition, anatomic- 
ally speaking, must be dealt with surgically. If the nasal pas- 
sages are free, and no evidence of mouth breathing is present, 
the treatment of this region can in no way improve the audi- 
tory function. In the same way a small amount of lymphatic 
tissue within the pharyngeal vault in patients over twenty 
years of age does not demand removal unless it gives rise to 
some special disturbance. In young subjects, however, I am 
disposed to deal radically with any lymphatic hypertrophy in 
this region if there is the slightest evidence of impairment 
of hearing, since in early life lymphatic tissue is particularly 
prone to vascular changes from comparatively slight causes. 
Adenoid growths, then, should be removed surgically, either 
by the forceps or curette, or absorption effected by the appli- 
cation of chemical agents. Of these, a solution of the nitrate 
of silver, introduced through the anterior nares after the parts 
have been rendered insensitive by cocaine, will be found to 
be effective. A solution of sixty grains of nitrate of silver to 
the ounce may be applied to the part by means of the cotton- 
tipped probe, care being taken not to distribute the solution 
over the walls of the nasal cavity, nor to use it so freely as to 
allow it to pass into the lower pharynx. Hypertrophy of the 
turbinated bodies, if excessive, may be dealt with surgically, 
but usually cauterization with chromic acid will be sufficient. 
Obstructive lesions due to deformity of the septum may be 



TREATMENT— INFLATION. 365 

removed either with the saw, trephine, or galvano-cautery, 
as the operator deems most expedient. 

Concerning the removal of the faucial tonsils, it is my be- 
lief that they may cause secondary engorgement within the 
naso-pharynx, and hence, if they are hypertrophied, their re- 
moval is indicated when met with in childhood or early adult 
life. After this period this rule naturally does not apply. 

The Eustachian canal usually requires special measures to 
determine its return to the normal degree of patency. Where 
the obstruction depends merely upon venous engorgement or 
oedema, attention to the upper air passages, together with in- 
flation of the middle ear with air, will be effective without 
any other measures directed to the tube. The beneficial 
effect of inflation upon the calibre of the Eustachian canal 
depends upon the fact that when the normal calibre is re- 
stored for a short time by the passage of a current of air 
which temporarily relieves the engorgement, it gradually re- 
tains its normal patency. The air douche drives the blood 
out of the distended venous channels and permits them to re- 
sume their normal tone, in much the same manner as an 
elastic bandage relieves venous engorgement of the extremi- 
ties. If, however, actual hypertrophy has taken place, stimu- 
lation of the mucous membrane may be necessary in order to 
effect restoration. This is particularly true in instances in 
which excessive secretion is present. The pharyngeal orifice 
of the tube is the part first affected, and the changes are most 
marked in this region. Before attempting any local medica- 
tion, the mucous membrane must be thoroughly cleansed from 
adherent secretion, otherwise our application will have but 
little effect. This may be done by washing out the pharyn- 
geal orifice of the tube with an alkaline solution, such as a 
weak solution of bicarbonate of soda, or the ordinary Dobell's 
fluid, or a solution of boric acid of about twenty grains to 
the ounce, to which may be added half a drachm of Listerine. 
This cleansing is effected b} r employing a device which con- 
sists of a Eustachian catheter the extremity of which is closed, 
while the curved portion of the instrument is supplied with 
lateral perforations. Fluid injected through this instrument 
does not enter the lumen of the tube, although the trumpet- 
shaped orifice is thoroughly washed and freed from any tena- 
cious secretion. The solution may be injected by means of 
a common ear syringe inserted into the outer end of the in- 



366 CHRONIC CATARRHAL OTITIS MEDIA. 

strument, or the syringe may be provided with a conical tip 
which fits it exactly. The mouth of the tube may also be 
cleansed by wiping it out with a pledget of cotton, the appli- 
cator being curved like the Eustachian catheter. After thor- 
oughly cleansing the pharyngeal orifice of the tube, it should 
be touched with an astringent solution. A solution of nitrate 
of silver, ten to thirty grains to the ounce, is the application 
most used. In older cases the application of equal parts of 
compound tincture of iodine and glycerin is efficient. Even 
where the tube is involved for a considerable distance beyond 
its pharyngeal aperture, treatment of this region may cause 
absorption of the newly deposited tissue. If this fails, applica- 
tions may be made to the entire length of the canal, either bv 
means of stimulating vapors or of medicinal solutions. The 
precise manner of carrying out these measures has already 
been given. Dilatation of the Eustachian canal by bougies is 
exceedingly efficacious where the deposit is of long standing, 
the mechanical stimulation due to the presence of the instru- 
ment within the lumen of the tube causing absorption of the 
new-formed tissue. If the walls of the tube seem much re- 
laxed and the obstruction recurs quickly, although the tube 
may admit the passage of a bougie of considerable size, it is 
well to leave the instrument in position for several minutes to 
restore the normal tone of the tissues. Medicated bougies 
may be used, but their employment is difficult, and presents 
no advantages over topical applications made in the manner 
described under tubal congestion. 

The injection of fluids into the tube and tympanum is 
never wise. It is true that excellent results have occasional- 
ly- been obtained by this means, but the same object may be 
accomplished without subjecting the patient to the serious 
possibilities which the injection of fluid into the tube entails. 
Although the tympanic portion of the Eustachian canal is 
inclosed in firm, bonv walls, it should always be remembered 
that an obstruction may lie at the tympanic orifice of the 
tube; and although we can not dilate the osseous canal, we 
may overcome an obstruction in the locality above named, 
and should never fail to pass the instrument through the en- 
tire length of the canal until the tvmpanic cavity is entered. 
Relaxation of the mucous lining may occur even in this re- 
gion, and topical applications may be beneficial. In many 
instances an inspection of the membrana tympani will reveal 



TREATMENT— REMOVAL OF FLUID. 



367 



the bougie in the tympanic cavity. It usually lies behind and 
a little below the short process of the malleus, and by pres- 
sure can be made to push the drum membrane over it out- 
ward into the canal. 

The changes within the tympanum may consist of an ac- 
cumulation of fluid, localized or diffuse hypertrophic changes, 
and adhesions. When fluid is present, its removal should be 
effected through the Eustachian tube if possible. To this 
end, the operation of inflation should be performed with the 
head of the patient inclined a little forward and toward the 
opposite side ; the current of air, upon entering the tvmpanum, 
will then force the fluid through the Eustachian tube into the 
pharyngeal vault. When this takes place, the sound heard 
upon auscultation changes in character from that character- 
istic of fluid within the tympanum to the harsh, bubbling 
sounds which are indicative of secretion at the pharyngeal 
orifice of the canal. Subsequently auscultation reveals an 
entire absence of bubbling sounds as the air enters the cavity. 
When removed in this manner, the effusion is apt to accumu- 
late a second time. To prevent this, it is wise to follow the 
simple inflation with the introduction of a medicated vapor 
into the middle ear. The vapor of compound tincture of ben- 
zoin, of eucalyptus, menthol, alcohol, ether, iodine, or any 
other volatile drug which possesses mild stimulating properties 
may be used. The length of time during which the applica- 
tion shall be continued will depend upon the effect produced, 
the degree of irritation should not be sufficient to amount to 
actual pain, and the patient should be conscious of but a mod- 
erate stinging sensation as the current enters the tvmpanum. 
If the fluid accumulates a second time, or if our efforts at 
evacuation through the tube are not successful, the membrana 
tympani must be incised. Only very general rules can be 
given as to the proper point of locating the incision, since the 
fluid may be encapsulated in some of the reduplications of the 
lining membrane. If the entire cavity is filled, however, it is 
best to make the incision in the posterior quadrant, dividing 
the membrane from a point just below the posterior fold to 
the inferior pole, the line of section running parallel to the 
peripheral attachment of the membrane. This incision may 
seem unnecessarily free, but the results obtained are much 
better than where a small opening is made, since a large 
opening permits complete evacuation of the fluid, and the 



368 CHRONIC CATARRHAL OTITIS MEDIA. 

parts heal within a few hours, with the development of no 
cicatricial tissue. A small opening remains patent for a 
longer period and is closed by a deposit of cicatricial tissue, 
and the tension of the drum membrane is altered. 

After the membrana tympani has been incised certain meas- 
ures may be necessary to cause the lining membrane of the 
middle ear to return to a perfectly normal condition, and 
thus prevent the reaccumulation of the fluid. These measures 
consist in the instillation of astringent solutions through the 
opening made, or their injection through the Eustachian tube. 
The former method is decidedly preferable, since the results 
obtained are equally good and the discomfort to the patient 
is much less. In certain instances a small amount of fluid re- 
mains in the cavity after the greater portion has been ab- 
sorbed; this remnant becomes inspissated and adheres closely 
to the lining membrane of the middle ear. Inflation of the 
tympanum fails to remove the collection either on account 
of its viscidity, or owing to the fact that it lies out of the 
direct air current. Under these conditions the tympanum 
should be thoroughly washed out with boiled water or with 
Thiersch's solution. This lavage ma) r be carried out either 
through the Eustachian tube or through an artificial opening 
in the membrana tympani. Where the object is to cleanse the 
cavity rather than to medicate its lining membrane, irrigation 
through the Eustachian tube is preferable, since all the re- 
cesses of the cavity are reached in this way and a considera- 
ble quantity of fluid may be used in irrigation. In carrying 
out this procedure the catheter should possess a rather sharp 
curve, and the curved portion should be somewhat longer than 
where the instrument is used for inflation simply. It should 
be of such size as to permit its entrance into the Eustachian 
tube for a considerable distance. Very little force should be 
used in injecting the fluid through the tube into the middle 
ear. The injection maybe made either with the common syr- 
inge or with a fountain syringe, the reservoir being raised to 
such a level as to permit the current to pass slowly. In this 
way any inspissated material is removed and the cavity thor- 
oughly cleansed. If proper aseptic precautions have been 
observed, the wound in the membrana tympani closes within 
thirty-six hours and usually reaccumulation does not take place, 
while the improvement in function is frequently considerable. 
It must be stated that although paracentesis affords a simple 



TREATMENT— TENOTOMY OF THE TENSOR TYMPANI. 369 

and efficient means of disposing of fluid within the tympanum, 
the collection is exceedingly liable to reaccumulate. When 
this occurs in individuals beyond fifty years of age it is un- 
wise to attempt any radical measures to prevent reaccumula- 
tion of fluid. Incision of the membrana tympani in these cases 
is not painful and affords complete relief for periods varying 
from a few weeks to several months. In advanced age the 
reparative processes of the body are decidedly below the nor- 
mal standard, and very slight causes easily excite a middle- 
ear inflammation. Our efforts, therefore, should aim rather 
to relieve these cases by successive operations than to attempt 
permanently to cure the affection by means which may result 
in a serious middle-ear inflammation. 

Under the impression that the continued pressure of the 
manubrium mallei upon the internal wall of the middle ear 
acted as an exciting cause of the inflammatory process, and 
that the maintenance of the malleus in this abnormal position 
was due largely to shortening of the tensor tympani tendon, 
Weber- Liel* advocated the operation of tenotomy of this 
muscle in these cases. If we could separate cases in which 
the inflammatory process depended entirely upon the spastic 
contraction of the tensor tympani muscle there is but little 
doubt that section of the tendon would be followed by com- 
plete cure. Unfortunately, we have no means of recognizing 
the fact that the process is so limited in extent, and experi- 
ence teaches that by the time the tendon is permanently short- 
ened other portions of the middle ear have become affected. 
The relief obtained by the operation was demonstrated by an 
improvement in the ear operated upon and also by a decided 
improvement in the organ of the opposite side, and both 
Weber-Liel and later Cholewaf have urged the advisability 
of the procedure for the purpose of preventing the extension 
of disease to the opposite ear. The only fault that can be 
found with the procedure is that it is not radical enough, as 
it corrects the increase in tension at but one point in the os- 
sicular chain. The tendon of the tensor tympani may be the 
locality in which the fibrous changes first manifest themselves ; 
but, before this condition is recognized, a diffuse hypertrophic 
process has involved a large portion of the membrane lining 

* Monatsschr. fur Ohrenheilk., 1868, Nos. 4 and 12. 
f Arch, of Otol., vol. xix, p. 151. 
25 



370 CHRONIC CATARRHAL OTITIS MEDIA. 

of the middle ear. It is our duty, then, to attempt the correc- 
tion of this condition as well as to direct our measures toward 
the contracted tendon of the tensor. 

In order that the mucous membrane of the tympanum may 
resume its normal condition after hypertrophic changes have 
once taken place, it is necessary to increase temporarily the 
blood supply of the part ; in other words, to create artificial- 
ly a moderately acute inflammatory process. The most con- 
venient method of effecting this change is to introduce some 
stimulating vapor through the Eustachian tube into the mid- 
dle ear in the manner described, at the same time removing 
all secondary causes which tend to increase the congestion of 
the tympanic lining. Stimulation by means of fluids injected 
into the cavity should not be undertaken unless an opening 
has been previously made in the membrana tympani. If in 
any given case it seems advisable to inject fluid into the mid- 
dle ear, care must be taken that the instruments employed in 
the operation, as well as the fluid itself, have been thoroughly 
sterilized by heat. I am decidedly in favor, where it is neces- 
sary to use fluids in this manner, to introduce them into the 
tympanum through an opening made in the membrana tym- 
pani for the purpose. 

The choice of medicated vapors in any given case will 
depend upon the rules given for their selection for a simi- 
lar condition of the Eustachian tube in acute cases. If it 
seems wise to make use of drugs in solution, we should begin 
at first with weak solutions, such as a solution of zinc chlo- 
ride, two grains to the ounce ; zinc sulphate, ten grains to 
the ounce ; or nitrate of silver, ten grains to the ounce. The 
strength of the solution may be increased until the desired 
effect is obtained. The fluid is introduced through the open- 
ing in the membrana tympani by means of the middle-ear 
syringe (shown in Fig. 99), or by the middle-ear pipette. My 
experience has been that where the process has advanced so 
far that the introduction of vapors does not produce the de- 
sired effect, no benefit is gained by the injection of fluids. 

Passive motion for securing greater mobility in the ossic- 
ular chain by stretching the newly deposited tissue is not 
indicated here, as when the disease is in this hypertrophic 
stage it constitutes an active inflammatory process, which 
may be aggravated by mechanical irritation. The amount of 
motion imparted to the ossicles by catheter inflation preserves 



TREATMENT— MECHANICAL SUPPORT. 



371 



their motility sufficiently without the employment of other 
measures in this direction. Where the tension of the ossicu- 
lar chain is relaxed, great improvement sometimes follows 
the use of an artificial support, as first suggested by Blake.* 
This may consist of a small pledget of cotton inserted in front 
of the short process of the malleus so as to press upon it, 
crowding the ossicle backward and inward, or a narrow strip 
of thin rubber may be used, the ends of the strip being 
brought together and grasped in the forceps, and carried into 
the canal so that the convexity of the fold in the strip of rub- 
ber rests against the short process. Upon removing the for- 
ceps the ends of the rubber separate, impinging upon the 
anterior and posterior walls of the canal, while the convex 
surface of the strip presses against the short process of the 
malleus and crowds the ossicle against the incus. Failing to 
check the progress of the disease by any of the above meas- 
ures, or in cases of long standing in which sclerotic changes 
are beginning to take place, as evidenced by marked retrac- 
tion of the membrana tympani, exaggeration of the posterior 
fold, and the presence of atrophic areas in the drum mem- 
brane itself, resort must be had to surgical measures. These 
comprise tenotomy of the tensor tympani, as already men- 
tioned, division of an exaggerated posterior fold (plicotomy), 
section of intratympanic adhesions binding the ossicles to 
each other or to the tympanic wall, or separation of the drum 
membrane from the internal wall of the middle ear, to which 
it may have adhered ; all are of value in special cases. The 
only objection to them lies in the fact that the lesion is sel- 
dom limited to one particular region. The evidence of in- 
creased tension within the conducting chain is unmistakable, 
but in almost all cases the entire conducting chain is involved, 
and not one particular portion. 

Where the membrana tympani alone is the seat of the ob- 
struction the establishment of an opening through the drum 
membrane is beneficial. Its permanency was long ago shown 
to be the exception rather than the rule, however. If the 
membrane is relaxed, its tension may be corrected by apply- 
ing a disk of thin paper over the relaxed area. If the paper 
disk is moistened before it is applied it will maintain its posi- 
tion upon drying. My own practice has been, whenever im- 

* Arch, of Otol., vol. xxi, p. 166. 



372 CHRONIC CATARRHAL OTITIS MEDIA. 

pairment of function has seemed to depend entirely upon a 
middle-ear lesion, and when satisfactory improvement has not 
been obtained by the employment of measures detailed above, 
to remove the membrana tympani, malleus, and incus, and to 
divide subsequently adhesions about the stapes and about the 
round window. The membrane may be reproduced, but the 
septum thus formed is thin, comparatively insensitive, and 
possesses but slight vitality. Its removal is easily effected a 
second time, or even a third time if necessary, after which a 
permanent opening- usually remains. The chief value of the 
procedure lies in the fact that it enables us to free the stapes 
from adhesions which may subsequently develop and be a 
source of serious functional impairment. 

The subject of surgical interference in these cases and the 
technique of the various operations is considered in the section 
devoted to the operative surgery of the middle ear. 

Chronic Hyperplastic Otitis Media. 

iEtiology. — The hyperplastic form of tympanic inflamma- 
tion may develop from the form described in the preceding 
section ; rarely it follows a purulent otitis media ; it may also 
occur as an idiopathic affection. The cases belonging to the 
idiopathic group may follow a severe illness, physical or men- 
tal exhaustion, and malnutrition. They may depend upon 
interference with the trophic nerve supply of the middle ear. 
Sex exerts a certain influence, females being more frequently 
attacked than males, from which we assume that exposure 
plays but little part in the causation of the affection. A se- 
vere mental shock, such as fright, may exert a causative in- 
fluence in the disease under consideration. The influence ex- 
erted by any abnormal condition in the upper air passages is 
usually of but slight importance except in those cases which 
follow the hypertrophic form of inflammation. The disease 
may attack both ears, or the organ of but one side may be 
affected. When the condition is present upon both sides the 
organ last affected may become involved only after many 
years, and it frequently happens that patients do not dis- 
cover any impairment of hearing until the previously healthy 
ear is affected, when examination reveals marked impair- 
ment in the hearing power of the opposite side. The affec- 
tion is to an extent hereditary, especially in those cases of 
neuropathic origin, although this factor in causation is prob- 



PATHOLOGY. 373 

ably much overrated. Hyperplastic inflammation of the 
middle ear is most common between the ages of forty and 
fifty, although it may develop in early adult life, or even in 
childhood. Its development in advanced age is rare. 

Pathology. — The changes which the mucous membrane 
undergoes have already been touched upon. They consist 
of an increase of fibrous tissue in the mucous membrane lin- 
ing the tympanum, which becomes firm and dense in consist- 
ency and less vascular. The augmentation of the fibrous ele- 
ments causes atrophy of the glandular structures and dimin- 
ished secretion results. As the tissues undergo this fibrous 
metamorphosis they become dense, and the normal ligaments 
which support the ossicles within the middle ear and which 
bind them to one another are shortened. In addition to 
these changes in the lining membrane, a certain amount of 
new tissue is deposited, forming bands of adhesions between 
the ossicles and the internal wall of the tympanum, displac- 
ing the ossicular chain and binding it firmly to the osseous 
walls of the middle ear. The membrana tympani is usually 
unchanged in the early stages, but by stretching may become 
atrophic in places, or by prolonged contact with the internal 
wall of the tympanum may become adherent to it. The 
hyperplastic changes are usually more marked in the region of 
the oval or the round window, in the former position binding 
the stapes firmly in the pelvis ovalis ; while occurring in the 
latter locality they prevent free oscillation of the membrana 
tympani secundaria. When the stapedio-vestibular ligament 
is involved, the foot plate becomes firmly fixed in the foramen 
ovale, and in cases of long standing bony sclerosis may oc- 
cur. The tendon of the stapedius muscle with the mucous 
folds which commonly invest it undergoes shortening, caus- 
ing displacement and fixation of the stapes, the posterior 
crus being drawn toward the adjacent wall of the oval niche, 
to which it contracts adhesions. All of these changes about 
the oval and round windows may occur without displace- 
ment of the membrana tympani, or without giving rise to 
any changes discoverable upon ocular inspection. 

When the upper part of the cavity is much involved, the 
entire ossicular chain is frequently displaced inward, dimin- 
ishing the breadth of the tympanic cavity without rotation of 
the ossicles about the axis band. In other cases the fibres 
may be so disposed as to draw the tip of the manubrium in- 



374 



CHRONIC CATARRHAL OTITIS MEDIA. 



ward, exaggerating the anterior and posterior folds and giv- 
ing rise to a picture similar to that seen when the Eustachian 
tube is closed, the handle of the malleus lying almost hori- 
zontal, the short process being prominent. 

The changes may involve the upper part of the cavity 
primarily, and lead to rotation of the malleus about its long 
axis, increasing or diminishing its apparent breadth, as ob- 
served in speculum examination. A process sclerotic from 
the first does not give rise to the crumpled appearance in the 
membrana flaccida mentioned in the preceding chapter; this 
condition, according to Walb,* is characteristic of a secon- 
dary sclerosis following hypertrophic changes. The same may 
be said in general of most of the changes recognizable in 
otoscopic examination, marked displacement of the ossicular 
chain usually indicating a preceding hypertrophic process. 

The inflammatory process is not limited to connective 
tissue alone, but may involve the osseous structures as well. 
When this occurs the shaft of the malleus may present irreg- 
ularities due to localized periostitis. 

Labyrinthine involvement of various grades may occur 
even in the early stages. It may be so slight as to escape 
notice or in advanced cases so extensive as to play an impor- 
tant part in the impairment and perversion of the function. 
When both ears are affected the labyrinthine involvement is 
frequently more marked upon the side last involved. 

The changes occurring in the Eustachian tube result in an 
undue patency of the canal ; this condition exposes the parts 
within the tympanum to traumatism from violent efforts at 
coughing, sneezing, or clearing the nose. The tubal muscles 
are also involved, becoming atrophic quite early in the course 
of the disease. 

Symptomatology. — In the early stages the affection is so 
insidious that considerable damage occurs before the atten- 
tion of the patient is directed to the ears. Subjective noises 
are present in a large number of instances, and often cause 
more distress than the impairment of hearing. They appear 
early in the affection, as a rule, and increase in severity as 
the disease progresses. Slight attacks of giddiness may also 
occur in the early stages, but are usually attributed by the 
patient to a disturbance of digestion or to some irregularity in 

* Schwartze, Handb. der Ohrenheilk., Leipzig, 1893, vol. ii, p. 198. 



SYMPTOMATOLOGY. 



375 



the habit of life. The impairment in hearing is at first mod- 
erate, and its advance is so gradual as not to be noticed by 
the patient until both organs are involved, or until one is se- 
riously affected. Pain of neuralgic type and intermittent in 
character is occasionally present in these cases. The attacks 
of pain are usually of but short duration, the patient com- 
plaining that several times during the day there has been a sud- 
den sharp pain in the throat radiating toward the ear. Occa- 
sionally a dull headache referred to the orbital region of one 
or both sides is complained of. This is apt to persist for a 
considerable length of time, and the patient feels entirely un- 
fitted for any kind of mental or physical labor, the entire sen- 
sorium being to an extent blunted. This dull mental condi- 
tion causes considerable depression, which in turn aggravates 
both the impairment in function and the distress caused by 
the tinnitus. As the result of this impairment of the general 
nervous tone, the condition of the patient may approach that 
seen in melancholia, and in certain instances the patient may 
develop a suicidal mania and attempt to take his own life 
rather than bear the distress which the tinnitus occasions. 
The perverted mental condition affects the general nutrition 
of the body, and the patient loses flesh, becomes anaemic, 
and to all appearances is suffering from some severe con- 
stitutional malady, producing pronounced neurasthenic symp- 
toms. 

In the more advanced stages the impairment of hearing is 
of a somewhat peculiar type,- in that it undergoes marked 
changes from no other assignable cause than the effort made 
by the patient to understand conversation. When attention 
is not particularly drawn to the fact that the power of audi- 
tion is being tested, the hearing may be fairly good ; the 
moment, however, the patient is conscious that a test is be- 
ing made of his ability to hear certain sounds, the impair- 
ment increases to a marked degree, and words which a few 
moments before have been understood perfectly well are not 
heard. The facies which these patients present is somewhat 
characteristic, being indicative of intense mental strain, due 
probably to their efforts to conceal their affliction. 

It must be admitted also that the constant effort to hear 
which these patients exert is responsible for the condition of 
impaired nervous tone from which they suffer. The fatigue 
of the higher centres from this constant strain can not fail 



376 CHRONIC CATARRHAL OTITIS MEDIA. 

to exert a profound influence upon the nerve elements and 
lead to nerve exhaustion. 

A curious mental perversion which many exhibit, in addi- 
tion to the depression of spirits already spoken of, is the feeling 
of suspicion with which they regard even their most intimate 
acquaintances. As they can not understand general conver- 
sation, the patients in whom the neurotic tendency is pro- 
nounced seem to feel that any remark made in a low tone 
refers to their condition and is a direct reflection upon them. 
For this reason many become averse to performing their 
social duties and isolate themselves as completely as possible. 
It is hardly necessary to state that this action tends rather to 
increase than to relieve the functional impairment. 

After the disease has persisted for a long time the tinnitus, 
which was at first distressing, may become less marked, or 
may disappear completely. When both ears are involved, the 
tinnitus is often more severe upon the side last affected. This 
is undoubtedly due to the fact that labyrinthine changes upon 
the side primarily affected have gone on to such a degree 
that the portion of the labyrinth which normally responds 
to sounds similar in character to the tinnitus from which they 
formerly suffered has been completely exhausted, and no 
longer reacts to stimulation due to increased pressure. 

Diagnosis. — A. Physical. — These cases present, upon ex- 
amination, appearances which vary widely, according to the 
course which the affection has pursued. When the process 
has been sclerotic from the first, the ear may present no 
changes upon inspection. The position of the light reflex 
may be normal ; the lustre of the membrane may be pre- 
served ; the density may be uniform, and no deviation from 
the normal position may be recognizable. Under these con- 
ditions we are usually correct in assuming that the process 
has been of the hyperplastic type from its incipiency, and 
that the deposit of fibrous tissue has taken place chiefly about 
the oval and round windows. Occasionally inspection of the 
inner extremity of the osseous meatus will reveal a slight 
change in color, the cutis being of a somewhat pinkish tinge. 
This is indicative of the presence of an inflammatory process 
within the tympanic cavity, and shows that the disease is still 
in an active stage. Where the membrana tympani has be- 
come slightly atrophic we may observe a similar congestion 
affecting the inner tympanic wall, which imparts a slightly 



DIAGNOSIS— PHYSICAL EXAMINATION. 



377 



pinkish tinge to the otherwise normal membrana tympani. 
The thinning of the membrana, particularly of the upper and 
posterior segment, may enable us to see the long process of 
the incus, the incudo-stapedial articulation, and stapedius 
tendon in their normal position (Fig. 95). In other instances 
we may have slight sinking inward of the membrana tym- 
pani, with rotation of the malleus about its long axis. If 
rotation has occurred from behind forward, the shaft of the 
malleus appears somewhat broader than normal, and of a 
dead-white color (Fig. 102). This change in color is due to 
atrophic changes in the overlying fibrous layer. When ro- 
tation takes place in the opposite direction we usually have 
considerable retraction of the membrana tympani, exaggera- 
tion of the anterior and posterior folds, and the fundus of 
the canal assumes a more circular contour (Fig. 104). In 
these cases a sharp edge of the prismatic shaft of the manu- 
brium is presented to view, which causes the shaft to appear 
narrower than normal. In cases of long standing, especially 
if met with in advanced life, the inflam- _ 

matory process may have induced certain 
changes in the periosteal covering of the 
manubrium mallei, as the result of which 
irregularities in outline appear upon the 
shaft. These are really calcific deposits in 

., . . , . -, ,1 r Fig. 104.— Moderate 

this periosteal covering, and are worthy ol retraction of the 
note, as they suggest the possibility of simi- dmm membrane 

. . , 7 , . . . and slight narrow- 

er deposits within the tympanic cavity in mR G f the malleus 

the neighborhood of the oval or round win- h . andle from rota " 

& . tion. 

dow. Where the degree of depression of the 
drum membrane is considerable the process has usually super- 
vened upon preceding hypertrophic changes. The increased 
tension to which the membrana tympani has been subjected 
has resulted in an attenuation of its fibrous layer, and inspec- 
tion of the underlying intratympanic parts is possible. In ad- 
dition to these changes, it is not uncommon to find the drum 
membrane adherent in places to the inner wall of the tym- 
panum, particularly at the umbo. The position of the light 
reflex varies with the degree of inclination of the membrana 
to the w 7 alls of the canal, but is of little diagnostic impor- 
tance. As mentioned before, changes in the membrana flac- 
cida are of diagnostic importance in determining the devel- 
opment of disease upon a preceding hypertrophic process. 




378 CHRONIC CATARRHAL- OTITIS MEDIA. 

When this has occurred, the membrana flaccida presents a 
crumpled appearance, and may be adherent to the neck of 
the malleus. In cases that have been hyperplastic from the 
start Shrapnell's membrane presents no such changes, but 
preserves its normal conformation, although its color may be 
slightly lighter than in health. Deposits of lime salts in the 
membrana tympani are seldom seen, although, when the con- 
dition is met with in advanced life, such deposit may be pres- 
ent along the annulus tympanicus. 

B. Functional Examination. — The hearing power is dimin- 
ished to a varying degree for both whispered and spoken 
words. The degree of impairment for sharp noises, such as 
the tick of a watch or the sound of an acoumeter, varies with 
the amount of labyrinthine involvement present, and hence 
constitutes an unsafe test for estimating the power of audi- 
tion when the case first comes under examination, or sub- 
sequently for determination of the improvement which has 
followed as the result of treatment. Quite frequently the 
hearing power for the watch and the voice will be dispropor- 
tionate. The watch may not be heard at all, while spoken 
or whispered words may be heard for a considerable distance, 
and the patient may consider this ear better than its fellow, 
although upon the opposite side the watch may be heard at a 
considerable distance, while the voice can not be understood 
as well as on the other side. This depends upon the fact 
that the labyrinthine changes impair the hearing for sharp 
sounds, such as the tick of a watch, since these lie in the up- 
per portion of the musical scale, while that portion of the 
musical register which is made use of in conversation lies in 
the lower portion of the scale, and may be perceived, al- 
though considerable labyrinthine involvement is present. In- 
terference with the conducting mechanism, on the other hand, 
impairs the hearing first for the lower notes, and hence con- 
versation is heard more poorly in the ear possessing the most 
marked tympanic involvement. 

The lower tone limit is considerably elevated. Bone con- 
duction is increased where the changes are confined to the 
middle ear. The fork placed upon the vertex is referred to 
the poorer ear provided only middle-ear changes have taken 
place, but where serious labyrinthine changes have occurred 
it may be referred to the better ear. This is not invariable, 
however, for, as already stated in pathology, changes in the 



DIAGNOSIS— FUNCTIONAL EXAMINATION. 



379 



perceptive apparatus in the ear last involved often progress 
with great rapidity, becoming in a short time more extensive 
than in the organ first affected. When this is the case the 
vibrating tuning fork applied over the median line of the skull 
may be referred to the ear which was first affected, although 
this may be the poorer ear. This should not mislead the ex- 
aminer into believing that the trouble upon the side to which 
the fork lateralized is entirely free from labyrinthine trouble. 
Increased tension in the conducting system may be sufficient 
to produce this phenomenon, even when the labyrinth is in- 
volved to a considerable extent. Absolute bone conduction 
may vary according to the age of the patient as well as with 
the degree to which the labyrinth has suffered ; hence this 
test yields but little information. When absolute bone con- 
duction is exaggerated we are justified in assuming that no 
serious labyrinthine involvement exists. In cases occurring 
in advanced life, however, the labyrinth may be intact, al- 
though sound conduction through the cranial bones is below 
normal. 

Of much more value than absolute bone conduction is the 
relative duration of sound perception through the solid media 
as compared with the period during which the same sound is 
heard through the air. In this manner we are able to esti- 
mate with considerable certainty the amount of impairment 
depending upon the labyrinthine changes, as distinguished 
from that caused by the intratympanic lesion. In a given 
case, where whispered words are but poorly perceived, if the 
reversal of the relation between air and bone conduction ex- 
ists for a fork making 512 V. S. (double) or for a fork of the 
next higher octave, we are warranted in assuming that most 
of the impairment depends upon intratympanic changes. 
With the same degree of functional impairment, if this re- 
versal should occur only for a fork making 64 V. S., while 
for the octave above this the air conduction was better than 
bone conduction, we should assume that serious labyrinthine 
changes had taken place. 

The determination of the upper tone limit is of great value 
in these cases in confirming the fact that the labyrinth is in- 
volved. The first turn of the cochlea perceives the highest 
notes of the musical scale, and secondary labyrinthine degen- 
eration should be characterized by a lowering of the upper 
tone limit, as this portion of the cochlea is in the most imme- 



380 CHRONIC CATARRHAL OTITIS MEDIA. 

diate relation to the middle ear and is the part which suffers 
first in secondary labyrinthine affection. When functional 
examination shows a defect at the upper portion of the scale, 
persisting after anomalous tension has been corrected by in- 
flation, labyrinthine involvement is almost certain. A history 
of attacks of vertigo is confirmatory of this opinion. 

Prognosis. — Hyperplastic changes within the tympanum 
constitute an affection of the gravest character as regards the 
integrity of function, and one which is less amenable to treat- 
ment than all other aural diseases. The usual course is stead- 
ily progressive, although the affection may remain quiescent 
for a long period of years. 

Knowing this fact, it is difficult to estimate the value of 
treatment in any given case, the apparent improvement being 
possibly due to a period of spontaneous quiescence. When 
seen in the early stages, and affecting but one side, a fairly 
favorable prognosis may be given. When both organs are 
affected it will be impossible to restore either ear to a perfect 
condition. The most we can hope for is a slight improve- 
ment in one or both, and to check permanently the progress 
of the affection. Aside from treatment, the environment of 
the patient or the occurrence of any severe illness affect the 
progress of the aural condition to a marked extent. A severe 
illness, prolonged physical exertion, overwork, or anxiety — all 
tend to hasten its advance. From the fact that many cases 
are of neuropathic origin, particular attention must be paid 
to the habit of life. All excesses, either of the table or un- 
due indulgence in tobacco or alcohol, should be avoided, and 
the preservation of a normal condition of the larger viscera 
and of the prim as viae must be insisted upon. Climate is a factor 
in prognosis only to the extent to which it causes impairment 
of the general health. Since a dry atmosphere and an equa- 
ble temperature are most conducive to a normal condition of 
the upper air tract, the disease perhaps progresses less rapid- 
ly in regions where these climatic conditions are found. I 
am inclined to believe, however, that the influence of climate 
has been much overestimated. The age at which the affec- 
tion develops may influence its progress. When occurring 
late in life, its advance is usually slow unless aggravated 
by some cause, such as a severe intercurrent disease, mental 
strain, or prolonged physical exertion. Its appearance at the 
menopause is not uncommon, and Our prognosis in incipient 



TREATMENT— PASSIVE MOTION. 



381 



cases met with at this period of life should be exceedingly 
guarded. 

Treatment. — The two conditions with which we have to 
deal are those resulting from the connective-tissue deposit 
within the tympanum and the secondary labyrinthine changes. 
The intratympanic condition being one essentially of rigidity 
of the ossicular chain, our first efforts are to relieve this ab- 
normal tension. When seen early it may be possible to effect 
absorption of the newly deposited tissue by stimulation of 
the mucous lining of the tympanum ; this is done by inflation 
by means of the catheter, making use of some of the stimulat- 
ing vapors already mentioned in the treatment of hypertro- 
phic inflammation. By inflating with considerable force we 
may be able to rupture recent adhesions and thus relieve the 
conducting mechanism, or the bands may be stretched suffi- 
ciently to permit increased mobility in the ossicular chain. 
The Eustachian tube seldom requires attention, although the 
exercise of the tubal muscles, either by gargling of or better 
by massage by means of the Eustachian bougie, may correct 
the changes which have taken place here. This massage also 
exerts a favorable influence 
upon the tensor tympani 
muscle and prevents its 
atrophy and subsequent 
shortening. To massage 
the tube in this way the 
bougie is introduced as far 
as the isthmus and then 
moved rapidly inward and 
outward for a few seconds. 
Passive motion by means 
of Siegel's otoscope affords 
us a means of combating 
the adhesions. The instru- 
ment should be introduced 
into the meatus, care being 
taken that it fits the lumen 
air-tight. The air is then 
alternately rarefied and 

condensed in the external auditory canal, imparting to-and- 
fro movements to the drum membrane and attached os- 
sicula. The masseur of Delstanche (Fig. 105) acts upon the 




Fig. 105. — Delstanche's masseur. 



382 • CHRONIC CATARRHAL OTITIS MEDIA. 

same principle. Cases have been reported where rupture 
of the membrane has taken place by the violent use of these 
instruments ; this seems hardly probable, however, if even 
an ordinary amount of care is taken in their manipula- 
tion. In the same direction manipulation of the parts at the 
hands of the patient has been tried, in some cases with suc- 
cess. The method was first devised by Homell and consists 
in pressing the tragus backward over the external meatus 
until this is completely closed, thus condensing the air in the 
canal. By now alternately increasing and relaxing the press- 
ure upon the tragus the density of the air in the canal is 
augmented or reduced and the drum membrane made to 
perform inward and outward excursions. 

Poiitzer has devised a method for maintaining a constant 
negative pressure in the meatus by the use of a conical plug 
of cotton which is impregnated with cocoa butter. This plug 
is inserted into the canal at night, and, in virtue of its oleagin- 
ous composition, absorbs the air contained within the meatus, 
thus causing the membrana tympani to move outward under 
the action of the air within the middle ear. I have had no per- 
sonal experience with this plan, but in cases where it has been 
tried I have failed to see any benefit. It is certainly inferior 
either to Homell's method or to systematic manipulation with 
the Siegel otoscope. 

Lucae * has met with considerable success in applying pas- 
sive motion to the ossicular chain by means of the pressure 
sound. The device consists of a small tube through which a 
rod terminating in a cuplike extremity passes. The other 
end of the rod lies within the tube and rests upon a small spiral 
spring the tension of which is regulated by a small screw on 
the handle of the instrument. In use, the cup-shaped extrem- 
ity is applied to the short process of the malleus, over which 
it fits, the manipulation being effected under illumination. 
Pressure inward upon the handle of the instrument is com- 
municated to the ossicular chain, the degree of pressure de- 
pending upon the tension of the spring. By pressing the han- 
dle of the instrument inward and then relaxing the pressure, 
the entire ossicular chain is alternately forced inward and then 
allowed to resume its former position through its own elas- 
ticity. It has been demonstrated that pressure exerted at the 

* Arch, fur Ohrenheilk., vol. xxi, p. 84. 



TREATMENT — MASSAGE— OPERATION. 383 

short process of the malleus is communicated directly through 
the incus to the foot plate of the stapes, and from this to the 
labyrinth. The advantage of the device over an ordinary 
probe consists in affording us the means of alternately increas- 
ing and diminishing this tension without removing the instru- 
ment from the short process of the malleus, as its continual re- 
application would be attended by considerable pain. In my 
practice a modified manipulation similar to this has not been 
attended by favorable results. 

The use of the instrument of Lucae is somewhat painful. 
Many patients, especially in private practice, would object to 
the measure, and it has never seemed that the results ob- 
tained warranted the infliction of so much discomfort. The 
length of time during which this method of treatment should 
be carried on must vary with the individual cases. 

It has never seemed wise to me to give an absolutely un- 
favorable prognosis in any case where the lesion was confined 
mostly to the middle ear without trying the effect of stimula- 
tion of the lining membrane by means of vapors for a period 
of four to six weeks, the inflation being performed at first on 
alternate days and the interval gradually increased to three 
or four days. In addition to the inflation, passive motion by 
means of the Siegel otoscope may be employed, or, if it seems 
desirable, the use of the pressure sound. At the end of this 
period, if no improvement results, surgical measures are im- 
perative, and, unless the degree of improvement is considera- 
ble, the same advice should be given. During this period 
the observance of the ordinary hygienic rules should be in- 
sisted upon ; but attention to the upper air passages is seldom 
followed by marked improvement, unless there have been 
symptoms referable to these parts demanding treatment for 
their relief. 

The surgical measures to be adopted in these cases will de- 
pend upon the physical condition present. It may be suffi- 
cient to divide tense bands which may be seen by ocular in- 
spection, such as an excessive deposit of connective tissue in 
the posterior fold, or adhesions between the tip of the manu- 
brium and the internal tympanic wall. As mentioned in a pre- 
ceding chapter, however, it is impossible to assert that the 
increase in tension is due to the presence of adhesions in any 
one particular locality. The procedure, therefore, which 
seems most wise is at first an exploratory myringotomy un- 



384 CHRONIC CATARRHAL OTITIS MEDIA. 

der strict antiseptic or aseptic precautions. A large flap in- 
volving- the entire postero-superior segment of the membrana 
vibrans should be turned downward and forward, the intra- 
tympanic structures inspected, and the degree of mobility of 
the stapes determined by means of a delicate probe introduced 
through the opening. This procedure can be conducted un- 
der cocaine anaesthesia and tests can be made of the hearing 
at various stages of the operation. Occasionally the artificial 
opening into the tympanum may improve the hearing power 
to a remarkable degree; if this does not occur, disarticulation 
at the incudo-stapedial joint should be the next step. If the 
stapes is movable, the hearing will now be improved ; if this 
ossicle is fixed, however, but slight improvement will be no- 
ticed. The stapes must then be freed by division of the sta- 
pedius tendon and of any adhesions lying in the oval niche, in 
the manner to be described in the chapter on operative pro- 
cedures within the tympanum. After the adhesions have been 
severed as completely as possible passive motion should be 
employed, the stapes being crowded first upward, then down- 
ward, then forward, and finally backward by means of a deli- 
cate steel probe the extremity of which is protected with a 
small cotton pledget firmly wound upon it. The condition of 
the round window should also be investigated and adhesions 
in this region severed with an angular knife. If the degree of 
fixation is extreme it may be wise to attempt extraction of the 
stapes, although the results obtained are not perfectly satisfac- 
tory, and the author prefers to remove the malleus, incus, and 
drum membrane, leaving the stapes in an easily accessible po- 
sition, so that subsequently mechanical mobilization may be 
effected if fixation occurs again at any future time. I am 
aware that this method has been criticised, but it possesses 
the advantage of freely exposing the parts and enabling us to 
make successive efforts at freeing the stapes rather than ne- 
cessitating the completion of all operative interference at the 
time of the first operation. Certainly in my own practice re- 
sults have been better where this plan has been followed than 
where stapedectomy has been performed, and the opening in 
the drum membrane closed as quickly as possible. The op- 
erative technique and the results obtained will be detailed in 
a later chapter, devoted to the subject of middle-ear opera- 
tions. 

The measures herein enumerated constitute the most effi- 



TREATMENT— INTERNAL MEDICATION. 385 

cient means at our disposal for dealing with the intratym- 
panic conditions. When the labyrinth is involved to any 
extent operative interference is contraindicated, since the 
cases do not improve after such procedures, but are frequently 
rendered worse. The extent of labyrinthine involvement in 
any given case is determined by the degree to which the 
upper tone limit is lowered and by discovering the upper 
limit in the musical scale at which the normal ratio between 
air and bone conduction is reversed. With a marked lower- 
ing of the upper tone limit and an inversion of the ratio be- 
tween bone and air conduction for the low notes alone, in 
cases where the impairment of hearing is so marked that 
whispered words can not be distinguished at a distance of 
two or three feet from the ear, the labyrinthine feature is so 
prominent as to positively contraindicate operative interfer- 
ence upon the tympanum. The result of treatment for the 
labyrinthine affection is usually less favorable than in primary 
labyrinthine disease. At the same time, we are at least justi- 
fied in making the attempt to remove the difficulty. 

The drug, the administration of which is followed by the 
best results, is undoubtedly pilocarpine. The physiological 
action of the drug increases the vascularity of the labyrin- 
thine tissues, at the same time augmenting the activity of the 
cutaneous and salivary glands. From the increased blood 
supply any excess of labyrinthine fluid is abstracted from the 
bony cavity which contains it, entering the general circula- 
tion and subsequently being eliminated in the cutaneous or 
salivary secretions. The increased vascularity may also cause 
the resorption of newly deposited tissue, provided the deposit 
is not too old. Formerly the drug was administered by 
hypodermic injection. This, however, renders it necessary 
for the patient to give up a considerable portion of each day 
to the treatment, and in many instances this can not be done. 
For the last two years I have administered it by the mouth, 
beginning at first with doses of one eighth to one sixth of a 
grain two or three times daily, the amount being gradually 
increased until a moderate physiological effect followed each 
exhibition. It is only necessary to warn the patient to exer- 
cise caution against exposure to draughts for the period of 
an hour and a half following each administration of the rem- 
edy. ■ In those cases where the vocation of the patient neces- 
sitates absence from home for the entire day one dose may 
26 



386 CHRONIC CATARRHAL OTITIS MEDIA. 

be administered early in the morning immediately upon rising, 
while the second may be given upon retiring at night. In 
this way the patient is able to protect himself sufficiently 
against undue exposure, and by following this plan no un- 
toward symptoms have resulted. Profuse salivation need not 
be produced, nor need the cutaneous secretion be increased 
to such a degree as to be unpleasant. A moderate increase 
in the moisture of the skin and in the amount of saliva is an 
evidence that the drug is producing the desired effect, and 
the patient learns after a short time to so grade the dose as to 
obtain the desired action. No results can be hoped for unless 
the plan is persisted in for a considerable period — certainly 
for two months — at the end of which time, if the slightest 
improvement is manifested, it should be continued for twice 
or thrice this period. 

According to Kosegarten,* the remedy exerts a beneficial 
action upon the mucous membrane of the tympanum also, 
causing an absorption of newly deposited connective tissue. 
It is possible to observe a congestion of the tympanic lining 
if the patient is examined one or two hours after the adminis- 
tration of the drug. Politzer advocates the local application 
of the muriate of pilocarpine to the mucous membrane, a few 
drops of a two-per-cent solution being injected through the 
Eustachian catheter. Personally I have no experience with 
this plan. 

In cases of hyperplastic inflammation occurring in ad- 
vanced life the auditory nerve may be found in a condition of 
torpor. Here strychnine may be given with advantage, the 
amount being gradually increased to the full physiological 
limit. This drug is also valuable in cases with pronounced 
neurasthenic symptoms. For the relief of distressing tinnitus 
which persists in spite of all local treatment directed toward 
the middle ear dilute hydrobromic acid will sometimes be 
found efficacious. This is to be given well diluted, in doses 
of thirty minims, three or four times daily. The question of 
subjective noises will be more fully dealt with under diseases 
of the perceptive apparatus. The possibility of an hereditary 
or an acquired specific taint should always be remembered in 
these cases, and if there is the slightest evidence of such a 
factor in causation the internal administration of iodide of 

* Archives of Otology, vol. xvii, p. 95. 



TREATMENT— HYGIENE. 387 

potassium is advisable. It may be given either alone or in 
connection with the pilocarpine. 

The question of the propriety of treating- the middle-ear 
condition when serious labyrinthine involvement coexists is 
still unsettled. The results obtained, no doubt, differ in in- 
dividual cases, but I am sure that the rule is not constant 
that measures directed to the middle ear invariably aggra- 
vate the labyrinthine lesion. Our only guide in the matter is 
to examine our cases frequently and observe the effect of 
treatment. If we find that inflation, passive motion, or other 
measures directed to the tympanic condition, produce giddi- 
ness or an increase in the tinnitus they should certainly not 
be persisted in. Numerous instances will be met with in 
which exactly the reverse takes place, the labyrinthine com- 
plications improving as the tympanic structures resume a 
more normal condition. From what has already been said 
under prognosis, the general condition of the patient must be 
kept constantly in mind, and care must be taken to tax either 
his mental or physical powers as little as possible. Attention 
to the cutaneous, digestive, respiratory, and circulatory organs 
is imperative if we expect any favorable results from local 
measures. It is not wise to send these cases from home in 
the hope of obtaining permanent benefit from a change of 
climate, as the results obtained by climatic treatment are at 
the best uncertain. 



CHAPTER XXII. 

CHRONIC PURULENT OTITIS MEDIA. 

/Etiology. — This disease may follow either an acute ca- 
tarrhal or an acute purulent inflammation of the tympanic 
cavity. In the former instance it occurs as the result of an 
infection of the discharge through atmospheric impurities, 
while as a sequel of the latter condition it represents the fail- 
ure upon the part of Nature to restore the affected structures 
to a normal condition. The term is often applied to all 
cases of aural disease in which the discharge from the mid- 
dle ear has existed for more than two or three months, or 
even to cases in which the ear is discharging when the pa- 
tient presents for treatment. Exactly when an affection 
ceases to be acute and becomes chronic is hard to deter- 
mine. For convenience, however, we may assume that a 
discharge from the middle ear which has failed to yield to 
proper therapeutic measures at the end of three months con- 
stitutes a symptom of a chronic inflammatory process. 

A tubercular and occasionally a specific diathesis also may 
give rise to the affection, the special germs of these diseases 
finding lodgment in the tympanum and setting up the pecul- 
iar inflammatory process characteristic of each. When the 
disease is of tubercular nature its onset is so insidious that 
the patient may not be able to state the exact period of its 
inception, the first knowledge which he has of an aural affec- 
tion being the appearance of a discharge in the meatus, while 
examination reveals a condition which could only result from 
a chronic inflammatory process. 

Pathology. — When we find a purulent discharge from the 
tympanum which has persisted for a long period we* are 
forced to conclude that a certain amount of tissue necrosis 
has taken place. This is true whether the disease was at first 
of a catarrhal nature or was purulent from the beginning. 
The infection of a perfectly innocuous discharge from the 
tympanum must result in tissue necrosis unless the source of 

(388) 



PATHOLOGY. 



389 



infection is removed at a very early period. Those parts of the 
tympanic cavity which are richly supplied with connective- 
tissue elements form an excellent nidus for the development 
of these germs, and when they are once infected it is prac- 
tically impossible for us to prevent considerable destruction 
of tissue. In the early stages the connective tissue alone may 
be involved, but very soon the osseous structures participate in 
the process, owing to an interference with their proper blood 
supply. Those parts are attacked first which are the least 
vascular and whose nutrient vessels are so situated as to be 
easily interfered with by any increase in pressure in the tym- 
panic cavity. The blood supply of the incus, it will be re- 
membered, is very limited, and is derived from the petrosal 
branch of the stylo-mastoid. From its situation its calibre is 
easily obliterated by any swelling in the upper portion of the 
tympanum. Hence when the ossicular chain is the seat of 
necrosis the incus usually suffers first, caries or necrosis of 
this ossicle being present in eighty-five per cent of all cases in 
which the ossicles are involved. The process may spread to 
the walls of the tympanum, usually to that portion of the ex- 
ternal wall which is formed by the auditory plate of the tem- 
poral. The internal wall of the middle ear is seldom affected, 
although it may be involved when the condition is tubercu- 
lar, or in cases following one of acute infectious diseases, such 
as scarlet fever or diphtheria. Since any profuse discharge 
from the meatus which has existed for several months must 
come from the middle ear, it goes without saying that the 
membrana tympani is perforated in all cases. The amount of 
local destruction and the particular region where the loss of 
substance occurs varies greatly. Complete destruction of the 
drum membrane is rarely seen, although the entire membrana 
vibrans may be wanting with the exception of the so-called 
cartilaginous ring, which marks the line of insertion into the 
annulus tympanicus. When only a small portion of the drum 
membrane is destroyed the perforation most frequently oc- 
curs in the posterior quadrant at the level of the umbo or 
slightly below it. When the osseous structures are involved 
and the disease has been of long duration we not infrequently 
find the perforation located in the upper and posterior quad- 
rant just below the incudo-stapedial articulation. The mem- 
brana tympani in these cases is often adherent to the internal 
wall of the middle ear ; its upper margin, however, is free, 



390 



CHRONIC PURULENT OTITIS MEDIA. 



and a probe passed beneath this may be directed upward into 
the tympanic vault, following the long process of the incus. 
The reason why this perforation is so characteristic of caries 
within the tympanum depends upon the fact that the avenue 
of exit for any fluid which has collected lies along the long 
process of the incus. In fact, this may be the only course 
which the secretion can follow, as no other portion of the 
ossicular chain passes from the upper part of this cavity into 
the atrium. Anteriorly the atrium is shut off from the tym- 
panic vault by the anterior and external ligaments and by the 
body and neck of the malleus. In addition to these structures, 
normally present, certain reduplications of mucous membrane 
are often found, and these may be so numerous and so dis- 
posed as to render it impossible for even air to pass from the 
vault of the tympanum into the cavity beneath. Perforation 
in this location is so commonly associated with caries of the 
incus that I have come to regard it as almost pathognomonic 
of the condition. More rarely we find the perforation located 
in the membrana flaccida, either just above the short process 
or above the posterior, or, more rarely, above the anterior 
ligament. A perforation above the short process always 
means intratympanic caries, and usually indicates that the 
malleus is affected, although this rule is not invariable. The 
extent to which the walls of the tympanum participate in the 
destructive process varies according to the care which has 
been exercised in keeping the ear properly cleansed, and the 
degree of infection which primarily produced the disease. 
Constitutional diatheses exert a marked influence upon the 
extent of involvment of the osseous walls ; this is particularly 
true of the tubercular and specific diatheses, the bony parts 
breaking down rapidly when once local infection has taken 
place. 

Secondary involvement of the labyrinth is seldom met 
with in chronic suppuration. When present, the mischief has 
usually been done in the acute stage of the disease, and al- 
though both the oval and the round window may have re- 
mained bathed in pus for years, extension to the labyrinth 
seldom follows. This should not be taken to mean that the 
lower turn of the cochlea is functionally perfect in these 
chronic cases. It is more reasonable to explain the slight 
changes found here upon the ground that they are produced 
by the alteration in pressure at the oval window due to adhe- 



PATHOLOGY— CHOLESTEATOMA. 39I 

sions about the stapes than to attribute the condition to an 
infection of the labyrinth. 

Secondary involvement of the mastoid process constitutes 
the most grave complication from which these patients suffer. 
When drainage through the external canal is free the mastoid 
is seldom involved. If, however, the outflow through the 
canal is obstructed, the pus finds its way into the pneumatic 
spaces of the mastoid, an osteitis is set up, and more or less 
extensive bony destruction takes place. A change of con- 
siderable importance, and one which is always present to a 
greater or less degree, is a chronic inflammation involving 
the mastoid. This is essentially a chronic proliferative oste- 
itis, through which the pneumatic spaces are obliterated, and 
the entire mastoid process becomes converted into dense 
eburnated bone. This change may be so complete that all 
the air spaces are obliterated, and the antrum itself may be 
reduced in size. Only in those cases which have persisted 
for a long period of years and in which the process has been 
active is no trace of the atrium found. 

The development of a cholesteatoma following chronic 
suppurative otitis depends upon the inflammatory process as- 
suming a particular type, as the result of which the superficial 
epithelium covering the mucous membrane is formed rapidly 
and as rapidly desquamated, while the fluid products of in- 
flammation are slight or practically absent. As the result of 
the casting off of these epithelial cells there are formed, first 
in the vault of the tympanum, and later in the mastoid itself, 
irregular masses of epithelium, in which the cells are firmly 
packed together. This process depends upon the transforma- 
tion of the superficial epithelium lining the tympanum into 
epidermal cells. The change is probably due to the exten- 
sion of the cutaneous lining of the canal into the middle ear 
through an opening in the membrana tympani. Such a con- 
dition follows perforation in Shrapnell's membrane more 
commonly than a solution of continuity in the membrana 
vibrans. In some instances these cutaneous cells become com- 
pletely covered by the mucous membrane and by their pro- 
liferation from true cysts containing a mass of desquamated 
epithelium. 

The cases of cholesteatoma met with in which there is 
no evidence of a previous perforation of the drum mem- 
brane are probably the result of an inflammatory process 



392 CHRONIC PURULENT OTITIS MEDIA. 

in infancy, at which time the drum membrane was perfor- 
ated. 

The acute symptoms which may be caused by the pres- 
ence of a cholesteatoma and the treatment of the condition 
will be considered later. As these masses increase in size 
slowly but constantly, they dilate the cavity in which they 
lie, displacing the surrounding walls. The mechanical irri- 
tation, due to the presence of the mass, causes a condensa- 
tion of the osseous tissue, or mastoid sclerosis. Another 
condition which may result from the development of these 
epithelial masses is absorption of the bony wall separating 
the meatus from the mastoid cells, the mastoid cells and ex- 
ternal canal being converted into one large cavity. If the 
bony walls are absorbed in the opposite direction, perforation 
into the cranial cavity may take place. Products of inflam- 
mation may enter the cranial cavity by transmission through 
the perforating veins or by local necrosis over any given area. 
According to the location and the exact nature of the local 
lesion, such an invasion of the cranial cavity may result in an 
epidural abscess, a diffuse meningitis, a brain abscess, or a 
sinus thrombosis. 

Symptomatology. — The one prominent symptom is, natu- 
rally, discharge from the ear, and although extensive destruc- 
tion may have taken place, this may be the only symptom 
of which the patient complains. The amount of discharge 
varies, in some cases being so profuse as to fill the meatus in 
spite of frequent cleansing ; at other times being discoverable 
only upon inspection of the ear by reflected light, the secre- 
tion drying upon the walls of the meatus and never appear- 
ing at the orifice of the canal. The degree of impairment of 
hearing is never indicative of the extent of the local process. 
It is not uncommon to find the entire membrana vibrans 
wanting, the incus completely destroyed, and the malleus 
carious, and yet the power of audition not noticeably im- 
paired. In other cases, where the lesions are less extensive, 
a high degree of deafness is present. Subjective noises are 
much less frequently met with in chronic suppuration than in 
the nonsuppurative form of inflammation. Attacks of vertigo 
may be complained of, dependent upon no assignable cause, 
or they may occur only when the ear is syringed. The dis- 
turbance of equilibrium may be but slight or so pronounced 
as to cause the patient to fall. When this symptom appears 



SYMPTOMATOLOGY. 



393 



only upon syringing the ear, the drum membrane will usually 
exhibit a large perforation exposing the head of the stapes to 
the direct impact of the current. 

Chronic suppuration need not necessarily cause constant 
discharge from the ear. The patient may be free from the 
symptom for weeks or even years. This intermittency de- 
pends upon the precise nature of the local changes within the 
middle ear and also upon certain associated conditions of the 
upper air tract. In children where the membrana tympani 
has been extensively destroyed as the result of one of the 
exanthemata, we frequently have the history of a discharge 
from the ear only when the patient has a cold in the head. 
In such a case, usually, the internal wall of the middle ear is 
exposed over a very large area, and the mucous membrane 
covering it participates in any vascular changes which may 
take place in the associated organs. Hence an acute rhinitis 
or an acute naso-pharyngitis, especially if the pharyngeal ton- 
sil is hypertrophied, causes a similar hyperaemic condition of 
the mucous membrane of the middle ear. Add to this the 
exposure of the membrane by the loss of the membrana tym- 
pani, and it is easy to understand why the discharge recurs at 
such a time. The attack is really one of tubo tympanitis, but 
as the tympanum is freely open, the serous transudation ap- 
pears in the canal. In other instances inquiry will fail to 
elicit any history of discharge, but the patient may state 
that at intervals small yellowish-brown crusts collect in the 
meatus and constitute a source of annoyance. Careful ex- 
amination shows that these so-called crusts are masses of in- 
spissated pus which collect in the deeper portions of the canal 
and constitute a source of discomfort only when they appear 
at the orifice of the meatus. 

Certain symptoms referable to the external canal may also 
be present. The development of a fungus upon the walls of 
the meatus is not uncommon, as the parts are continually 
bathed in secretion. The symptoms may be so slight as to 
escape notice, or there may be an intense burning or stinging 
sensation in the ear, together with pruritus. Where proper 
attention is not paid to cleanliness, a circumscribed external 
otitis may result, producing the symptoms characteristic of 
this affection. Diffuse inflammation of the external meatus is 
rather uncommon unless the mastoid process is involved. 

The development of facial paralysis was formerly supposed 



394 CHRONIC PURULENT OTITIS MEDIA. 

to be indicative of involvement of the mastoid. This is by 
no means true. The facial nerve in its passage through the 
tympanic cavity is ordinarily completely inclosed in a bony 
canal, and pressure symptoms are impossible unless this bony 
wall is wanting at some portion, either as an anomalous ana- 
tomical condition or as a result of necrosis. In either of these 
conditions the trunk of the nerve may be pressed upon and 
facial paralysis of the corresponding side result. Where the 
canal is imperfect the nerve itself may become inflamed and 
the integrity of the facial muscles be impaired without any 
inflammatory changes taking place in the bony wall. When 
cholesteatoma develops, the pressure upon the nerve trunk 
may produce this symptom when the bony wall has been 
incomplete originally or has been partially absorbed by 
pressure. 

The occurrence of granulation tissue suggests the pres- 
ence of necrotic bone, provided the ear has been kept thor- 
oughly cleansed, and its recurrence after removal, with sub- 
sequent thorough cleansing, is pathognomonic of diseased 
bone. Where the parts have not been thoroughly freed from 
the discharge the action of the heat of the body, together 
with the moisture, induces exuberant granulations to spring 
up about the edges of the perforation in the drum membrane, 
and may often excite a similar process from the internal tym- 
panic wall or from the various reduplications of mucous mem- 
brane within the middle ear, although the osseous structures 
may not be affected. These granulations, when they are due 
to hypernutrition of the soft tissues, yield very rapidly to 
chemical caustics if the parts are kept thoroughly cleansed, 
and a careful observation of their behavior under treatment 
enables us to recognize the involvement of the bony parts 
with absolute certainty. Where the secretion is very scanty, 
amounting to but a fraction of a minim daily, it may not 
escape from the meatus at all, but adhere to the walls of the 
canal and form a crust upon the posterior or superior wall of 
the meatus. Close to the membrana tympani it spreads down- 
ward and conceals it more or less completely. The presence 
of such a scale should always lead us to suspect a suppurative 
process within the tympanum, although the patient may deny 
positively that the ear has ever been the seat of a purulent dis- 
charge. In these cases there has usually been caries of the 
ossicular chain. Most frequently the incus has been the seat 



DIAGNOSIS— PHYSICAL EXAMINATION. 



395 



of the destructive process which may have occurred in early 
childhood, although it may not be discovered until adult life. 
The perforation is frequently small and situated high up in 
the membrana tympani in its flaccid portion. It is in these 
cases that we may have serious mastoid complications if the 
condition is allowed to go on unchecked ; in fact, the mas- 
toid inflammation may be the first symptom which causes 
the patient to direct his attention to the ear. More rarely 
the case is still more serious and intracranial infection takes 
place and progresses so insidiously that the patient is beyond 
all hope before the trouble is discovered. 

The symptoms which characterize labyrinthine involve- 
ment are sudden dizziness, nausea, and profound deafness. A 
moderate involvement of the labyrinthine structures is com- 
mon in cases where the disease has persisted for a long pe- 
riod. Notwithstanding this fact, the hearing may be but lit- 
tle impaired, the labyrinthine affection being confined to that 
part of the organ which is concerned in the appreciation in 
the highest notes of the scale — tones which are but little used 
in carrying on the ordinary vocations of life. 

Diagnosis. — A. Physical Examination. — It is impossible to 
describe the manifold appearances which may be observed 
in chronic purulent otitis. For convenience we may divide 
them presented into six groups : 

i. Destruction of the membrana tympani over a large area, 
with thickening of the mucous membrane over the internal 




Fig. 106. — Chronic 
purulent otitis me- 
dia. Extensive de- 
struction of the 
membrana vibrans. 




Fig. 107. — Chronic puru- 
lent otitis media. Ex- 
uberant granulation tis- 
sue developing within 
the tympanum. 



■ 



Fig. 108. — Chronic puru- 
lent otitis media. Mem- 
brana tympani adherent 
along inferior margin of 
perforation. 



tympanic wall and hypersecretion from the exposed surface 
(Fig. 106). 

2. Extensive destruction of the membrana vibrans, with the 
development of granulation tissue over the internal wall of the 
middle ear (Fig. 107). 

3. But slight destruction of the membrana vibrans, usually 



396 CHRONIC PURULENT OTITIS MEDIA. 

in the posterior quadrant ; adhesions between the margin of 
the perforation and the internal tympanic wall, except at the 
upper border, where a sinus leads directly into the vault of 
the tympanum. In these cases granulation tissue may be 
present, protruding from the orifice of the sinus, or the 
channel may be perfectly free. This appearance is indicative 
of caries within the middle ear (Fig. 108). 

4. Membrana vibrans intact ; perforation through the mem- 
brana flaccida, above the short process of the malleus. Here 
granulation tissue may or may not be present. The appear- 
ance is always indicative of diseased bone (Fig. 109). 

5. Entire membrane swept away, except the cartilaginous 
ring and a small portion of Shrapneli's membrane which en- 




ml 

1 9 



Fig. 109. — Perfora- Fig. iio. — Chronic Fig. hi. — Chronic puru- 

tion above the purulent otitis me- lent otitis media. Small 

short process of dia. Ossicles dis- « perforation behind the 

the malleus. placed. umbo. 

velops the ossicula or their remnants, partial destruction of 
the chain, as a rule, having taken place. In these cases there 
is usually a sinus beneath the anterior or posterior ligament, 
sometimes in both situations (Fig. no). 

6. A small perforation through the membrana vibrans, the 
drum membrane otherwise intact. This appearance is met 
with in childhood, and is indicative of infection of a simple 
catarrhal inflammation of the tympanic cavity, due usually to 
neglect (Fig. 11 1). 

In inspecting any case, particular attention should be paid 
to an investigation of the entire periphery of the membrana 
tympani. Not only the membrana vibrans, but especially that 
part lying about the short process, should be carefully exam- 
ined. This latter step should be taken, although a perforation 
may be present in the lower portion of the drum membrane, 
which seems to explain sufficiently the presence of the dis- 
charge. A coexistent loss of substance in Shrapneli's mem- 
brane may be found which will modify decidedly the prog- 
nosis in the case. 



DIAGNOSIS— PHYSICAL EXAMINATION. 397 

The free use of the probe is not difficult in these cases, 
since the middle ear is scarcely sensitive. We should deter- 
mine whether the discharge really proceeds from an exposed 
surface or simply flows over this, originating in the upper part 
of the tympanic cavity. When this is the case, it will always 
be possible to insert a delicate probe under the posterior or 
anterior fold and carry it upward into the vault. The sim- 
plest means of doing this is to wind a pledget of cotton firmly 
upon a small cotton-holder, the cotton extending for some dis- 
tance beyond the end of the instrument. If wound firmly, 
this cotton tip possesses considerable power of resistance, 
and causes less pain upon impact than does a metallic in- 
strument. The cotton should be bent at a right angle, the 
angular portion being about one eighth of an inch in length. 
It is sufficiently firm to permit its introduction beneath the 
anterior or posterior fold of the membrana or into the small 
perforation in its lower portion. By manipulation it should 
be carried successively to the different parts of the middle 
ear, when, if exposed bone is encountered, the operator will 
recognize the fact by the cotton catching upon the rough 
surface. When this is not felt, it is well, upon removing the 
instrument, to examine the cotton carefully by means of a 
magnifying glass. Contact with exposed bone will pull out 
some of the strands, and this sign is as positive an evidence 
of caries as that afforded by the use of the probe in any other 
portion of the body. 

Granulation tissue may develop to such an extent as to 
completely fill the meatus, in which case its recognition is a 
matter of no difficulty. In cases where it comes through a 
perforation in the membrana flaccida, it may be so closely 
applied to the periphery of the perforation as to render the 
line of demarcation almost indistinguishable. Here the mis- 
take may be made of confounding the appearance with a 
bulging of the upper portion of the drum membrane, but 
careful manipulation with the probe will reveal the true na- 
ture of the condition. The granulation tissue pits easily on 
pressure, and the slight amount of mobility which it possesses 
points clearly to a pedunculated attachment. 

The mucous membrane covering the internal tympanic 
wall may resemble so closely the appearance of a bulged and 
reddened drum membrane as to mislead us, unless we bear in 
mind that where the membrana tympani is present we are 



398 CHRONIC PURULENT OTITIS MEDIA. 

able to follow any one wall of the canal continuously across 
the fundus until it merges into the opposite wall, the outline 
being- unbroken. If we are dealing with a case in which the 
internal wall of the middle ear is exposed, we shall find a 
solution of continuity at the very periphery, between the 
margin of the canal, which stops here abruptly, and the red- 
dened wall of the middle ear, which lies at a lower level. 
The recollection of this simple fact will render a mistake in 
diagnosis rare. 

The recognition of the ossicula is frequently a matter of 
no small difficulty. The short process of the malleus usually 
preserves its normal position more nearly than any of the 
other landmarks, and should be first sought. When this is 
recognized, if the shaft is present, we can usually make it out. 
If it does not lie in its normal position, or if it is found to be 
slightly displaced backward and inward, the head of the 
patient should be tilted far over toward the opposite side and 
the region between the short process and the internal tym- 
panic wall carefully inspected. Necrosis of the tip of the 
malleus is not uncommon, and then the manubrium is usually 
slender, and drawn upward and inward by fibrous bands and 
completely hidden from view by the prominent short process 
and the hypertrophied posterior and anterior folds. 

It is of special importance to inspect the upper and pos- 
terior quadrant of the field for an explanation of the degree 
of functional impairment. The stapes may frequently be seen 
in this region lying close to the margin of the tympanic ring, 
and partially concealed by it. If the head of the patient is 
inclined well to the opposite side, and at the same time tilted 
a little backward, we are able to look beneath the obstruct- 
ing margin, and can usually recognize the head of the ossicle. 
Where extensive destruction has taken place the long process 
of the incus is often wanting ; if present, it may occupy its 
normal position, the incudo-stapedial articulation being clearly 
visible. When the lower portion alone is destroyed the rem- 
nant is usually displaced toward the malleus, lying between 
the manubrium mallei and the head of the stapes. 

Too much stress can not be laid upon the importance of 
first cleansing the ear most thoroughly by means of the cot- 
ton pledget and employing the probe, lightly touching each 
prominent point before attempting to interpret the condition 
of the parts. In an ear which has been properly cleansed an 



DIAGNOSIS— PUNCTIONAL EXAMINATION. 



399 



exact diagnosis is not difficult if the normal anatomical posi- 
tion of the parts is borne in mind. Where any secretion is 
present an exact diagnosis is impossible, and a correct inter- 
pretation is the result more of good luck than of skill. In 
addition to the ossicula, certain landmarks may be recognized 
on the internal tympanic wall. In the anterior quadrant, 
either partly below or above the median plane, there is a 
hemispherical depression just at the margin of the ring, which 
marks the tympanic orifice of the Eustachian tube. In the 
posterior quadrant the promontory terminates close to the 
tympanic ring. This break in the outline marks the niche of 
the round window lying below the head of the stapes, and in 
a plane almost at right angles to the plane of the oval win- 
dow. Occasionally the niche of the fenestra rotunda is ex- 
ceedingly well marked, and when associated with a contrac- 
tion of the meatus at its inner end the promontory may be 
mistaken for an exostosis. 

Inflation by means of the catheter gives auscultatory 
sounds, which vary according as the middle ear is shut off 
from the Eustachian tube by adhesions, or where the tym- 
panic orifice is patent. When the inner extremity of the 
tube has been occluded by an hypertrophic process, no sound 
of air entering the tympanum is perceived, each compression 
of the bulb being heard as a faint, distinct, percussion sound. 
It is distinguished from the sound heard when the tube is 
occluded at the isthmus from the more immediate proximity 
to the ear of the observer, and also by the absence of mucous 
pharyngeal rhonchi, which usually accompany this latter con- 
dition. With a latent tube the sound varies from a full blow- 
ing sound where the perforation is large to a sharp whistling 
note when the air passes through a small opening. Fre- 
quently perforations in the upper part of the drum membrane 
do not modify the normal auscultatory signs because the 
tympanic vault is entirely shut off from the atrium by viscid 
pus or by adhesions, and inflation produces the characteristic 
impact sound as the air impinges upon the drum membrane. 

B. Functional Examination. — The hearing for sharp sounds 
is reduced, and conversational voice and whispered speech 
may be heard as well or better than either the watch or acou- 
meter. The lower tone limit is elevated ; the upper tone 
limit is frequently normal, especially where the parts are 
moist, and where the process has not existed for many years. 



400 



CHRONIC PURULENT OTITIS MEDIA. 



In some cases we find that high notes are better perceived 
than under normal conditions. Where the ear has been the 
seat of a purulent inflammation for a long- period of years, 
the upper tone limit is often considerably lowered. This 
indicates labyrinthine involvement, which is usually not pro- 
gressive. Bone conduction is increased in most cases. Where 
one side alone is affected, the tuning fork on the vertex is 
heard better by the affected ear ; the normal ratio between 
bone and air conduction is reversed for the lower notes of the 
scale, frequently for all notes below the c" — 512 V. S. The 
electrical irritability is usually increased while the middle-ear 
process is active ; when this is quiescent such a reaction to 
the galvanic current would be indicative of labyrinthine in- 
flammation or congestion. 

Involvement of the mastoid process is characterized by 
pain and tenderness over the mastoid region externally, and 
usually by a diminution in the amount of discharge. Within 
the canal we find the parts tender along the superior and pos- 
terior walls close to the tympanic ring. Very soon after the 
mastoid has been attacked the soft tissues in this region sag 
into the lumen of the meatus, narrowing the fundus, and in 
severe cases may lie in contact with the opposite wall. This 
prolapse of the supero-posterior wall of the bony canal is 
pathognomonic of an inflammatory process within the mas- 
toid, and we need no other indication before resorting to im- 
mediate operative measures. The temperature is in nowise 
indicative of extension in this direction ; quite frequently the 
temperature remains normal, although the pneumatic spaces 
in communication with the tympanic cavity have become in- 
volved. 

Prognosis. — We consider under prognosis, first, the degree 
of functional impairment which the patient will suffer ; sec- 
ond, the continuance or cessation of the discharge ; third, the 
danger to life. 

In considering the probable degree of functional impair- 
ment, we must remember in general that a suppurative inflam- 
mation endangers the hearing much less than does a nonsup- 
purative process. The amount of destruction that has resulted 
furnishes us few data upon which to base an opinion. The 
condition of the parts in the upper and posterior quadrant, 
however, may aid us in estimating the probable degree of im- 
pairment which will result; if the stapes is exposed and is 



PROGNOSIS. 401 

movable upon manipulation and the niche of the round win- 
dow is unobstructed, deterioration of the hearing should not 
take place beyond that originally present when the patient 
first comes under observation ; on the contrary we should 
expect it to improve considerably from the reduction of the 
inflammatory process and from surgical measures directed to- 
ward adhesions which may be present. When the stapes can 
not be seen but adhesions exist which, from their location, 
might fix it firmly, the chances of improvement are still good. 
With a normally movable stapes and where the round window 
is not occluded, it is not probable that any measure directed 
toward the middle ear will greatly increase the power of au- 
dition. In interpreting these appearances we naturally cor- 
relate the results of the functional and physical examinations. 
With labyrinthine involvement we may hope for improvement 
from internal medication, although a guarded opinion should 
be given as to the degree which will be attained. 

Concerning the cessation of discharge, the chief factor is 
the presence or absence of diseased bone and the extent to 
which the osseous tissues have been invaded. If we find that 
the bony ring has been involved and the disease is of long 
duration, it is quite probable that softening has occurred in 
regions inaccessible to instruments introduced through the 
meatus. If the ossicula alone are the seat of the necrotic pro- 
cess or if we believe that the walls of the middle ear are but 
slightly involved, our prognosis is then fairly good regarding 
the ultimate cessation of the otorrhcea. When no dead bone 
is present we should be able to promise absolutely that the 
discharge will cease under proper treatment. We can also 
promise that the danger of subsequent mastoid involvement 
will be removed. But in any given instance where the osseous 
structures have been invaded, to promise absolutely that the 
discharge will cease, is certainly unwise. 

Concerning the danger to life, we need only to remember 
that insurance companies constantly reject applicants suffer- 
ing from a chronic otorrhcea, to appreciate how grave a men- 
ace to life the condition is. Where the mastoid is not involved 
and an examination reveals no evidence of intracranial involve- 
ment at the time of the investigation, we can promise that by 
properly conducted treatment the process will not endanger 
the life of the patient. With mastoid involvement there is al- 
ways a certain element of danger dependent upon the degree ; 
27 



4 o2 CHRONIC PURULENT OTITIS MEDIA. 

when intracranial changes have already taken place the prog- 
nosis is very grave. The variations in conditions which influ- 
ence our opinion when the mastoid is involved will be fully 
discussed in a chapter on this subject. Subjective noises, as 
a rule, are not distressing in the disease under discussion ; but 
when present, it is difficult to secure a complete subsidence of 
tinnitus unless it results from an acute exacerbation of the 
chronic disease. 

Treatment. — In the treatment of these cases we endeavor 
to accomplish two results : first, to stop the discharge ; sec- 
ond, to improve the hearing and relieve the subjective dis- 
turbances if any are present. 

In order to accomplish the first purpose it is necessary to 
see that the ear is kept thoroughly cleansed in order that the 
combined influence of heat and moisture may be removed. If 
the patient is to be treated at the hands of the surgeon every 
day and the discharge is only moderate in quantity, this may 
be removed in whatever way seems advisable, either with the 
cotton pledget or by irrigation with the syringe. If the treat- 
ment is to be conducted by the patient, irrigation affords the 
only safe means by which this object can be effected. The 
frequency with which irrigation should be repeated depends 
on the quantity of discharge, which must not be allowed to 
accumulate in the canal. In children, where the process is 
very active, or in cases that have been neglected for a long 
time, it is well to begin by having the ear syringed every two 
hours. The attendant or the patient himself must be in- 
structed carefully in the manner of performing this apparently 
simple operation. In the large majority of instances if this is 
not done the pus will not be thoroughly removed from the 
canal by the procedure ; consequently particular attention is 
directed to this point. In the adult patient the ear is to be 
drawn upward and backward by grasping the auricle between 
the index and middle fingers of the left hand, thus straight- 
ening the auditory meatus. The syringe should have a blunt 
nozzle, rendering it impossible for it to be carried in the 
meatus far enough to impinge upon the membrana tympani. 
After the irregularities in the canal have been overcome in 
the manner described, the syringe should be introduced into 
the meatus as far as possible and directed inward and slightly 
downward and forward toward the tip of the nose. In young 
children the curves of the canal are best obliterated by pull- 



TECHNIQUE OF SYRINGING. 403 

ing the auricle outward and downward, as shown in Fig. 87. 
If the syringe is pointed upward and inward the fluid will 
cleanse the deeper parts more thoroughly than if the direc- 
tions just given for the use of the syringe in adult patients 
are followed. The irrigating fluid is injected with a moderate 
amount of force, and the return current holding the pus in 
suspension is allowed to flow into any convenient receptacle 
which the attendant, or even the patient himself, holds under 
the ear close to the side of the face. The temperature of the 
fluid is a matter of considerable importance ; both hot and 
cold solutions are painful when introduced into the meatus, 
and the sensations of the patient should guide us in choosing 
the proper temperature. The amount to be used at each 
irrigation should not be less than half a pint, and it is fre- 
quently advisable to use more. 

Concerning the choice of a fluid for this purpose, we may 
use either a bichloride-of-mercury solution (1 to 5,000 or 1 to 
8,000) or water which has been boiled and allowed to cool to 
a lukewarm temperature, or a saturated solution of boric acid, 
or a two-per-cent solution of carbolic acid, or any other con- 
venient solution. In cases which have formerly been under 
treatment, and the patients know by experience the effect 
which fluids have upon the ear, the surgeon may be told 
occasionally that the result of the so-called " wet treatment " 
has been to increase the discharge. Many of these patients 
are able to wipe out the ears very successfully with a small 
pledget of cotton twisted about a bit of wood or upon a 
metallic cotton holder. We should never disregard these 
statements on the part of the patient without some good 
reason, and it is well not to insist upon the use of fluids if 
there is evidence that these have formerly increased the 
trouble. 

The removal of the discharge causes the swelling of the 
tissues within the middle ear to diminish, and w T ith the disap- 
pearance of the congestion and oedema the discharge will 
diminish in quantity and the parts resume their normal ap- 
pearance. 

We should now carefully investigate as to the cause of the 
flow. If we find the mucous membrane within the middle 
ear exposed over a large area, as is the case when considera- 
ble of the membrana tympani has been destroyed, and the 
exposed mucous membrane is swollen, hypertrophied, turges- 



404 



CHRONIC PURULENT OTITIS MEDIA. 



cent, and moist, the indication is to cause an absorption of 
the hypertrophied tissue and restore the local circulation to 
a normal condition. Certain conditions of the upper air pass- 
ages may tend to keep up a state of chronic congestion within 
the middle ear, and investigation of the nose and naso-pha- 
rynx should never be omitted. 

Where adenoid vegetations are found, it is well to begin 
our treatment by their removal. Enlarged faucial tonsils do 
not as frequently cause trouble, but if the organs are excess- 
ively hypertrophied, they should be removed. Hypertrophy 
of the turbinated bodies or other marked obstructive condi- 
tions in the nasal cavity also demand treatment, in order that 
there shall be no barrier to the free venous flow from the 
middle ear. 

Applications should also be made to the exposed lining 
membrane of the tympanum. For this purpose solutions of 
nitrate of silver may be employed, beginning with a two-per- 
cent solution, and rapidly increasing the strength, according 
to indications, up to two hundred and forty grains to the 
ounce, if necessary. The copper salts, if employed, should be 
used in less saturated solutions — ordinarily of a strength of not 
more than ten grains to the ounce. The practice of allowing 
these patients to instil astringent solutions into the ear is not 
advisable, particularly aqueous solutions of sulphate of zinc 
with a small amount of glycerin added, to retain the astrin- 
gent for a longer time in contact with the mucous membrane. 
A solution of this sort affords an excellent soil for the devel- 
opment of the various vegetable molds, and this occurrence 
often follows its continued use. If the patient is able to visit 
the surgeon only occasionally the preparation which is best 
adapted for his use at home is an alcoholic solution of boric 
acid in the proportion of twenty grains to the ounce. Where 
the internal wall of the tympanum is exposed over a large 
area, this solution produces particularly good results, the alco- 
hol acting as a local stimulant to the parts, while, in combi- 
nation with boric acid, it possesses sufficient antiseptic prop- 
erties to keep the parts free from the development of any of 
the low vegetable organisms. It also exerts a decided astrin- 
gent action, preventing the formation of granulation tissue. 

The use of powders which the patient is to blow into the 
ear can not be too strongly condemned. Under no condition 
should the patient be supplied with any remedy in this form. 



INSUFFLATION OF POWDERS. 405 

Even in cases where the perforation is very large, it is pos- 
sible for a preparation of this character to dry into a firm 
crust after absorbing the discharge, and this crust may be- 
come so closely attached as to constitute a barrier to the free 
outflow of secretion, in case this becomes suddenly augmented 
in quantity at any time. Pus retention under these circum- 
stances does not differ from retention of purulent material 
from any other cause, and in a considerable number of cases 
death has resulted from the incautious use of powders. In 
the hands of the surgeon some of the astringent or stimu- 
lating powders are of great value. We sometimes find 
that after the discharge has been greatly reduced a small 
amount of moisture still persists, and the progress of the case 
stops at this point. The use of fluids in these cases seems to 
tend rather to keep up the discharge. The insufflation of a 
minute quantity of boric acid, oxide of zinc, iodoform, or a 
mixture of equal parts of alum and boric acid is frequently 
followed by a complete cessation of secretion, the ear remain- 
ing perfectly dry. The fact must be emphasized that but a 
minute quantity of any such preparation is to be used, just 
sufficient to cover the mucous membrane. In the case of 
boric acid a little may also be dusted upon the walls of the 
meatus, but the practice, sometimes recommended, of filling 
the canal w T ith the powder should never be adopted. In no 
case should powder be used even by the surgeon if an inter- 
val of more than forty-eight hours is to elapse before the next 
visit, and the patient should be directed immediately to 
syringe the ear thoroughly if at any time there is pain, giddi- 
ness or a considerable increase in the discharge. With these 
precautions I thoroughly approve of the use of powders, but 
under no other circumstances. 

In other cases we find that our efforts are unsuccessful, 
although most carefully conducted. This should always 
cause the suspicion of diseased bone in some portion of the 
tympanic cavity. Naturally this has already been sought 
in the first examination, but if treatment has been consci- 
entiously carried out in the manner described for a period 
of three to four weeks without reducing the quantity of 
the discharge considerably we may assume safely that dis- 
eased bone is the cause of the trouble. This applies to cases 
where no granulation tissue is present ; in many instances we 
find this additional symptom. Where, upon primary exami- 



406 



CHRONIC PURULENT OTITIS MEDIA. 



nation, exuberant granulations are present to such a degree 
as to fill the fundus of the canal, or even if confined to a 
limited area, these should be dealt with before methods other 
than simple cleansing are instituted. If the granulations are 
of small size they may be destroyed in situ by the chemical 
or potential cautery. The chemical agents employed for this 
purpose are chromic acid or silver nitrate, either of which 
may be fused upon the end of a metal probe and lightly ap- 
plied to the granulation tissue after thoroughly drying the 
area to be touched. Any excess of the agent must be wiped 
away by means of a dry pledget of cotton to prevent it from 
spreading over the entire lining membrane of the middle ear. 




Fig. 112. — Removal of aural polyp with the snare. 



Where the tissue is soft and but little elevated above the 
general surface of the mucous membrane, a saturated solu- 
tion of persulphate of iron may be employed. Chromic acid 
is more suitable for the destruction of large granulations 
than any other chemical agent, since severe inflammatory re- 
action very rarely follows its use. The manipulation of the 
actual cautery is difficult, and is rarely more efficient than 
the means above mentioned. Where the granulations are 
of larger size they should be removed by means of the cold 
wire snare (Fig. 112), the loop being carried upward to the 
base and made to surround it, when by drawing the wire 
•into the tube of the snare the growth is cut off close to its at- 



REMOVAL OF AURAL POLYPS. 



407 




Fig. 



113. — Removal of aural polyp with 
the sharp curette (natural size). 



tachment. I much prefer this method to evulsing the growth 
after it has been surrounded by the loop. A practice which I 
often employ in these cases is removal of the tissue by means 
of the sharp curette (Fig. 1 13). 
Instruments of various sizes 
are necessary in order to per- 
form the operation effective- 
ly in this manner. The cu- 
rette is carried into the canal, 
passed below the growth, 
and then raised so that the 
ring of the instrument will 
encircle it ; by moving the 
curette delicately it can be 
carried upward along the 
pedicle to its point of attach- 
ment; then, by pressing the 
instrument firmly against 
the wall of the canal, and at 
the same time drawing it outward, the mass is removed. 

This procedure is not painful if care is taken not to touch 
the walls of the meatus during the introduction of the instru- 
ment. The advantage of this method lies in the thorough 
extirpation of the mass, which is usually severed close to its 
base. After removal, a pledget of cotton is inserted into the 
canal and crowded rather firmly into the fundus to check 
whatever haemorrhage may occur. After a few moments it is 
removed and the parts thoroughly cleansed by the cotton 
pledget, after which the stump is cauterized. If, after a 
thorough removal in this manner and careful cleansing of the 
ear for a period of several days, the tissue reappears, dead 
bone is certainly present. No other condition but the pres- 
ence of a foreign body can cause this phenomenon, and meas- 
ures should at once be instituted to remove the offending 
substance. 

It often happens, in an ear which has been the seat of puru- 
lent process since early childhood, that the discharge ceases 
and the ear remains practically dry, but occasionally a small 
amount of offensive discharge appears at the meatus. It will 
frequently be found that this symptom is due to the presence 
of an aspergillus which has found lodgment and subsequently 
developed in the meatus or upon the internal tympanic wall. 



4 o8 CHRONIC PURULENT OTITIS MEDIA. 

Owing- to the presence of a slight amount of moisture it 
has developed in this situation, and afterward its presence 
increases the discharge, and thus facilitates its own growth. 
This fact is mentioned since its occurrence may mislead us as 
to the result obtained by previous treatment in any given case. 
In several cases in which the ossicles had been removed for 
caries, and the discharge had ceased completely, the patients 
returned after several months complaining that the discharge 
had reappeared. This was found to be due to the develop- 
ment of a fungus in the canal. Thorough cleansing and an 
application of a solution of the bichloride of mercury, in di- 
luted alcohol in the proportion of I to 2000, destroys such 
growths, and restores the parts to their previously quiescent 
condition. 

Where the discharge depends upon the lack of proper 
care in treating a previous acute catarrhal inflammation, we 
find that the perforation in the membrana tympani is of but 
small size, and that the purulent discharge is due to an infec- 
tion of the normal mucous secretion of the middle ear. After 
infection the fluid products are but imperfectly evacuated, 
owing to the narrowness of the opening. The first indication 
here is to secure free drainage by enlarging the opening with 
a blunt knife. If the fluid is viscid, it is frequently wise to 
make two diverging incisions, inclosing a V-shaped flap, to 
permit the complete evacuation of the contents of the cavity 
upon inflation of the middle ear. After thorough cleansing — 
first by inflation, and subsequently by irrigation of the tym- 
panic cavity by means of the middle-ear syringe (shown in 
Fig. 99), and thoroughly disinfecting the meatus — these cases 
may recover with no further treatment. If this does not 
occur, the lining of the tympanic cavity is to be stimulated 
by the injection of a mild astringent fluid, introduced by 
means of the tympanic syringe. The delicate delivery tube 
of the instrument is carried through the perforation and a 
sufficient quantity injected to fill the tympanum completely. 
We usually recognize the fact that a sufficient amount has 
been injected by the passage of the fluid through the Eusta- 
chian tube into the pharynx. We should never begin with a 
solution of nitrate of silver stronger than five grains to the 
ounce of water, subsequently increasing the strength as we 
find the parts tolerant to the drug. Only solutions sterilized 
by heat should be used in this manner, and the instruments em- 



TREATMENT OF DISCHARGE FROM MIDDLE EAR. 



409 



ployed must have been subjected to a similar process. Where 
the discharge still continues in spite of this treatment, and no 
condition is present in the nose or naso-pharynx which would 
tend to aggravate it, good results may often be obtained by ap- 
plying a paper dressing to the part after the middle ear has 
been thoroughly cleansed and the mucous membrane subjected 
to the action of appropriate drugs. This paper dressing was 
first used by Blake, and consists of a small bit of thin sized 
paper of appropriate shape, which is first moistened in a solu- 
tion of bichloride of mercury, 1 to 1,000, and conveyed into 
the middle ear by the forceps or upon the tip of the cotton 
holder. The surface of this disk of paper is applied to the 
drum membrane, and by manipulation so placed as to occlude 
the opening in it. When in position, its edges are firmly but 
delicately pressed upon, to secure close contact with the 
drum membrane at every point. The efficiency with which 
this has been done can be demonstrated by gently inflating 
the ear, when no perforation sound will be heard if the opera- 
tion has been satisfactorily performed. A little boric acid is 
now lightly dusted over the disk and the membrana tympani. 
This dressing will remain in place for a period varying from 
four days to two weeks, at the end of which time it will prob- 
ably have been carried toward the periphery of the mem- 
brane, exposing the margin of the perforation. Another 
dressing should now be applied in the same manner as before, 
overlapping the first disk, so that, as the exogenous growth 
of the membrane carries the first outward, the opening will 
be gradually occluded by the second dressing. The stimula- 
tion which the presence of this foreign body produces is fre- 
quently sufficient to effect a complete closure of the opening 
in the membrana tympani, while its protective action induces 
retrograde changes in the congested lining of the middle 
ear after securing free drainage by enlarging the opening. 
Where a sinus leading into the tympanic vault is present 
immediately beneath either the anterior or posterior fold, it is 
probable that the osseous structures have been involved by 
the inflammatory process. If we do not detect the presence 
of dead bone upon examination, the treatment detailed in 
the preceding pages may be followed for a few weeks ; but, 
in addition, the vault of the cavity should be irrigated by 
means of the tympanic syringe, the delivery tube being bent 
upward at its extremity, so as to admit of insertion into the 



4io 



CHRONIC PURULENT OTITIS MEDIA. 



sinus and injection of the fluid into the upper spaces (Fig-. 
114). Naturally such manipulation can only be carried on by 
the surgeon himself. The irrigation should be repeated at 
first daily, and subsequently less frequently, as the discharge 

diminishes in amount. In 
cases where bony necrosis 
has taken place the diseased 
bone may have been thrown 
off spontaneously, either dis- 
integrating- and discharging 
in the form of pus, or it may 
have come away as a se- 
questrum at some former 
time. 

Here the persistence of 
discharge depends upon the 
retention of the secretion 
in the reduplications of the 
mucous membranes in the 
vault of the cavity. It is 
warranted in attempting at first to 
Peroxide of hydro- 




FlG. 114. — Irrigation of the tympanic vault 
(natural size). 



for this reason we are 
check the discharge by mild measures, 
gen, either dilute or of full strength, has been highly recom- 
mended by some observers for the irrigation of this region; 
aside from the fact that the antiseptic action of this drug is 
visible, I see no reason why it possesses any advantages over 
other solutions which are known to destroy pathogenic bac- 
teria. Certainly its entrance into the mastoid cells is unde- 
sirable because of the pressure exerted by the gas evolved 
during its action. 

Failing in any of these simpler measures, we may feel cer- 
tain that the discharge is due to the presence of diseased 
bone, and when we are confident of this fact the only rational 
procedure is to remove it. The extent to which the bony 
structures are involved influences the prognosis materially ; 
if confined to the ossicles the discharge will certainly cease 
upon ossiculectomy and thorough curetting of the tympanic 
walls. If the process is so extensive as to involve the osse- 
ous walls in regions inaccessible to instruments introduced 
through the meatus, the removal of the ossicles may still be 
indicated for the purpose of securing free drainage of the 
intratympanic spaces, although the discharge may not entire- 



OPERATIVE PROCEDURES FOR OTORRHGEA. 411 

ly cease. When there is sagging of the superior wall of the 
canal, a history of previous mastoid symptoms or mastoid 
tenderness, and a purulent discharge so profuse that it must 
originate in a cavity of greater size than the middle ear, the 
ideal procedure is an external operation, completely exposing 
the pneumatic spaces of the mastoid, together with the walls 
of the tympanum. Theoretically, such an operation should 
always result in a complete cure. Practically, the results 
obtained up to the present time are hardly better than those 
which follow the removal of the ossicles and a curetting of 
the tympanum and adjacent spaces through the meatus. The 
latter procedure does not confine the patient to the house for 
more than a day, leaves no scar, and seems less formidable 
to the patient than does the procedure by external incision. 
The technique of these operations is considered elsewhere. 

Operative procedures can not be too strongly urged in all 
cases where the presence of diseased bone is made out either 
by tactile examination or is quite as certainly indicated by 
the persistence of the discharge in spite of appropriate treat- 
ment. 

Regarding the efficacy of the operation of excision of the 
ossicles and curettement of the tympanum, Ludewig* report- 
ed forty-two cures in seventy-five cases operated upon. Gru- 
nert f cited thirteen cures in twenty-eight operations, while 
the author $ reported nearly two years ago fifteen cures in 
twenty-nine cases operated upon, while in nine the discharge 
was greatly reduced in quantity. The author's later opera- 
tions have given about the same results. Of a total of forty- 
two cases, twenty-three have been cured, w T hile thirteen have 
been much improved. In the remaining six cases the ultimate 
history is unknown, although in all but two there was con- 
siderable improvement when the cases were last seen. In the 
two remaining cases the patients were seen but once after the 
operation. 

So far we have considered the effect of treatment upon the 
discharge alone. Concerning the function of the organ, it may 
be said that, in cases of extensive destruction of the membrana 



* Arch, fur Ohrenheilk., vol. xxx, p. 263. 
f Ibid., vol. xxxiii, p. 207. 

% Supplement to Reference Handbook of Medical Sciences, New York, 1893, 
p. 244. 



412 



CHRONIC PURULENT OTITIS MEDIA. 



tympani and the formation of adhesions between the ossic- 
ula, the power of audition may diminish slightly, owing to 
the increased tension, after the parts become perfectly dry. 
This fact does not render the necessity or advisability of stop- 
ping the discharge less imperative, since any resulting impair- 
ment of function can be corrected by division of the adhesions 
at a subsequent period, while the continued secretion of pus 
is a constant menace to life. Following surgical procedures, 
the function of the organ is usually improved where the hear- 
ing is considerably impaired before the operation. Where 
the hearing is but slightly impaired we need not fear that it 
will be reduced by the operative measures proposed. Lude- 
wig * reports a slight impairment of the hearing as a result of 
the operation in six cases out of seventy-five operated upon. 
In my own cases but one instance of this kind has occurred in 
fifty operations. Impairment of the function more frequently 
follows the cessation of the discharge from treatment with 
astringents or caustics than from the method now under con- 
sideration. We assume here that the impairment in function 
is due principally to the intratympanic lesion and not to any 
labyrinthine involvement. Extensive involvement of the laby- 
rinth would contraindicate an operation for the improvement 
of hearing alone, but should scarcely stand in the way of the 
procedure for the relief of the discharge. The relief of sub- 
jective noises can very rarely be promised from any form 
of treatment, although where the mucous membrane is very 
much congested we should hope to abate their intensity as 
we reduce the turgescence. It is never safe to promise re- 
lief from this symptom by operative measures. On the other 
hand, these last-named procedures seldom or never produce 
subjective noises. 

The changes which take place in the tympanic mucous 
membrane after the removal of the ossicles and of the rem- 
nant of the membrana tympani vary considerably in differ- 
ent cases. The most favorable change is one in which the 
mucous membrane gradually undergoes dermoid transfor- 
mation. If this occurs, the membrane no longer secretes, 
and the patient is not liable to recurrent attacks of dis- 
charge from the ear whenever the upper air tract becomes 
acutely inflamed. In children this transformation takes 

* Arch, fiir Ohrenheilk., vol. xxx, p. 263. 



TREATMENT OF OTORRHCEA AFTER OPERATION. 



413 



place only after a long period, but in adults we may hope 
for it in from eight to ten months after the operation. Cer- 
tain steps at the time of the operation may hasten this trans- 
formation. Thus, if a small segment of the membrana tym- 
pani is allowed to remain at the lower part, and the mucous 
membrane over the promontory immediately opposite this 
segment is denuded by means of the curette, this small flap 
will apply itself to the denuded surface and rapidly become 
attached. The superficial epithelium spreads over the wall 
of the middle ear, transforming it into a nonsecreting sur- 
face. Where the mucous membrane remains intact, even al- 
though our procedure may have stopped the discharge per- 
manently, we should remember that any severe congestion or 
inflammation of the upper air tract, such as a severe cold in 
the head, may produce a temporary otorrhcea ; this will usu- 
ally subside spontaneously when the exciting cause has dis- 
appeared. In order that this may happen, the canal must be 
kept free from any infection while the discharge lasts. This 
end may be attained by cleansing the canal with the syringe 
twice daily. The solution to be employed, should be of a 
mild antiseptic character. A solution of bichloride of mer- 
cury (1 to 8,000) answers the purpose admirably. After irri- 
gation the patient should instil a few drops of an alcoholic 
solution of boric acid (gr. xx to §j) or of bichloride of mer- 
cury (1 to 3,000) into the ear. 

If the discharge is but slight and the patient is seen daily 
it may be sufficient to dry the parts thoroughly with cotton 
and then apply one of the alcoholic solutions above men- 
tioned to the walls of the meatus and middle ear with the 
cotton applicator. If these measures are carefully carried 
out the discharge will cease in a few days. A condition 
which we may sometimes be called upon to combat by oper- 
ative interference is where this dermoid transformation takes 
place spontaneously in cases which have not been subjected 
to treatment. Where a small perforation is present in the 
upper portion of the drum membrane the epithelium of its 
outer surface occasionally grows into the tympanic cavity, 
where it proliferates, lining the entire vault with epidermis. 
Owing to the increased vascularity of the part, this new lin- 
ing membrane becomes the seat of a desquamative inflamma- 
tion, superficial cells being produced and thrown off more 
rapidly than under normal conditions. The cavity becomes 



414 CHRONIC PURULENT OTITIS MEDIA. 

filled with desquamated epithelial cells, and exactly the same 
result follows as when a similar condition is present in the 
external meatus. The bony walls of the cavity are absorbed, 
and at the same time undergo consolidation as the result of 
chronic osteitis. An acute inflammation in an organ thus 
affected causes a sudden augmentation in the volume of 
this epithelial mass, and increases the pressure upon the sur- 
rounding walls. Sometimes the process is so insidious that 
the patient may not be cognizant of morbid changes in the 
ear until these symptoms, due to the sudden change, su- 
pervene, and the surgeon may first be consulted when oper- 
ative measures alone will relieve the case. The problem 
which we have to solve in such an event is whether we shall 
relieve the symptoms by an operation through the canal, 
or whether it is necessary to open the mastoid. Experience 
shows that the changes may be confined to the vault of the 
tympanum. In recent cases, and where no marked mastoid 
symptoms exist, such as external tenderness, pronounced and 
extensive sinking of the posterior wall of the canal, and spon- 
taneous pain over the mastoid, lam inclined to prefer clear- 
ing out the vault of the tympanum through the canal as a 
primary procedure. Frequently this is sufficient, and entire 
relief to the pressure symptoms follows, while at the same 
time the purulent condition is permanently arrested. When 
the process has invaded the mastoid, any operative procedure 
must not only remove the accumulation within the cells, but 
must also place these pneumatic spaces in communication 
with the meatus, in order that subsequent trouble may be 
avoided. From the nature of the pathological condition it 
may be practically impossible to extirpate every vestige of 
the lining membrane which has undergone dermoid trans- 
formation, and a recurrence may take place. It is our duty 
to establish a condition which will enable any subsequent 
accumulation to be removed without a severe operation. To 
effect this the mastoid is opened in the usual way, and the 
cell structure obliterated by means of the curette, after which 
the dividing wall between the artificial opening and the me- 
atus is taken away, throwing the mastoid cells and external 
canal into one cavity. The posterior wall of the fibrous canal 
is divided longitudinally, and the two flaps thus formed turned 
back into the bony cavity and retained in position by a tam- 
pon of gauze. Any subsequent accumulation can now be 



THERAPEUTIC MEASURES IN OTORRHGEA. 



415 



removed in the manner ordinarily employed in dealing with 
desquamative external otitis. 

We have limited ourselves to local measures in consider- 
ing the treatment. In patients of a lymphatic habit, particu- 
larly in children, much benefit will be gained by the internal 
administration of iodide of iron in full doses. Where evi- 
dences of malnutrition exist as the result of some hereditary 
diathesis the exhibition of cod-liver oil and of the hypo- 
phosphites will be found beneficial. In the adult attention 
should be given to regulating the habits of life so as to dimin- 
ish the tendency to congestion in the upper air tract as much 
as possible. The use of alcohol, and in certain cases of to- 
bacco, is particularly to be interdicted, although the influence 
of the latter is comparatively slight. 



CHAPTER XXIII. 

OTITIS MEDIA PURULENTA RESIDUA. 

By this term we designate that class of cases in which a 
former purulent inflammation has resulted in a permanent 
destruction of certain of the tympanic structures. Either 
spontaneously or as the result of treatment, the discharge has 
ceased, and we are called upon to relieve symptoms due 
either to the adhesions which have developed within the 
tympanum or to certain changes which have resulted from 
the purulent inflammation. For convenience we divide these 
cases into two classes : 

i. Where the symptoms are acute or subacute. 

2. Where the symptoms are of a chronic character. 

i. Acute Cases. 

iEtiology. — The underlying cause in these cases is evident 
from the title applied. As an exciting cause we may have 
any of those operative in the production of the various varie- 
ties of acute inflammation, but we usually find an acute in- 
flammation of the upper air tract, either a simple coryza, an 
acute naso-pharyngitis, or an influenza of the epidemic char- 
acter. Among other exciting causes we must bear in mind 
those which operate through the external meatus, such as the 
insertion of any device into the canal for cleansing the ear, 
blows upon the auricle, and the development within the 
tympanum of some of the vegetable molds. 

Pathology. — The changes which take place vary widely 
according to the condition in which the previous inflamma- 
tory process has left the parts. Cases in which the mem- 
brana tympani has been almost completely destroyed, expos- 
ing a large area of the inner wall of the middle ear, present 
generally a simple venous hyperasmia of this membrane, re- 
sulting in oedema, and subsequently in serous transudation. 

The condition found here is similar to that described under 

( 4 i6) 



PATHOLOGY AND SYMPTOMATOLOGY. 



4T7 



acute catarrhal otitis media, or tubo-tympanic congestion oc- 
curring in an organ in which the membrana tympani is in- 
tact. In the cases under consideration the serous transuda- 
tion, which results from the inflammatory process, appears in 
the external auditory meatus as a discharge, for the reason 
simply that the opening in the drum membrane allows it to 
escape from the tympanic cavity. Where the membrana 
tympani is intact the same transudation collects within the 
middle ear. It is a matter of some importance to remember 
this, as such a discharge does not become purulent unless 
infected from without. If the external meatus is kept in a 
thoroughly aseptic condition, the disease is self-limited and 
the discharge ceases spontaneously at the end of a few days. 
On the other hand, if infection occur, a chronic purulent 
otitis may result. The remaining portion of the membrana 
tympani is affected, becoming hyperaemic, desquamating if 
the process is pronounced, and increasing in thickness. 
Where the upper portion of the drum membrane remains, 
and the intratympanic folds has become much thickened 
by the development of new connective tissue, these lamellae 
increase in volume, and may completely fill the vault. If this 
portion of the cavity is completely shut off from the atrium 
the subsequent transudation causes a bulging of the mem- 
brana flaccida, which may protrude into the canal so as to 
resemble closely a mass of granulation tissue. From the 
changes which have taken place it is usually so dense that the 
fluid inclosed can not escape by spontaneous rupture. The 
case then presents the characteristics of a primary acute pu- 
rulent inflammation of the middle ear, with the exception 
that the osseous walls become involved more quickly than 
when the affection is primary. Destruction either of some 
part of the ossicular chain or of the surrounding tympanic 
walls results, and with a subsidence of the acute symptoms a 
chronic purulent otitis remains. When cholesteatomatous 
changes have taken place the involvement either of the mas- 
toid cells or of the cranial cavity itself is exceedingly prone 
to occur. 

Symptomatology. — In the cases in which the membrana 
tympani is destroyed over a large area, the symptoms consist 
of a slight impairment of the hearing, occasionally with the 
development of subjective noises. The prominent feature, 
however, is the appearance of a discharge from the ear. 
28 



418 OTITIS MEDIA PURULENTA RESIDUA. 

This class of cases occurs most frequently in children of from 
eight to twelve years of age, in whom the chronic purulent 
otitis has followed one of the exanthemata in early life. Pain 
is not a prominent symptom as a rule, and were it not for the 
appearance of the discharge the attack would probably pass 
unnoticed. Occasionally we may have developed in the ex- 
ternal canal an area of circumscribed inflammation due to 
local infection ; when this occurs there is intense pain. In 
the cases in which the upper part of the cavity is affected the 
pain is severe, prostration well marked, the temperature is 
elevated from one to four degrees, and there may be no dis- 
charge, or, if present, it is usually scanty. The pain may be 
localized in the ear or may spread to the entire temporal 
region. 

The occurrence of facial paralysis very early in the attack 
is not infrequent. The function of the organ may be but 
slightly impaired, owing to the location of the affected area. 

Diagnosis. — The result of functional examination depends 
so much upon the previous condition that it need not be 
considered, acute symptoms alone demanding attention. 

Physical Examination. — Upon inspection, where we find 
that the destruction of the drum membrane has been exten- 
sive, the exposed lining of the tympanum is red, velvety in 
appearance, and coated either with a colorless watery dis- 
charge, or, at a later period this is opaque in character. 
The remnant of the drum membrane is thickened, turgescent, 
and cedematous. When examined before the process is far 
advanced, it may present a dead-white appearance, owing to 
a necrosis of the superficial layer of its epithelium. Removal 
of this epithelial covering reveals a turgidity of the underlying 
parts. Where the upper segment of the cavity is involved, 
the remnant of the drum membrane is intensely congested, 
thickened, and, together with the adjacent canal wall, bulges 
into the lumen of the passage, narrowing the fundus to so 
marked a degree as completely to fill the inner extremity of 
the canal in some cases and prevent an inspection of the re- 
gion of the atrium. This obstructing mass may be movable 
upon manipulation with the probe, and present many of the 
characteristics of granulation tissue. Impact with the probe 
shows that it is too firm and dense for granulation tissue. It 
does not bleed easily when touched, and, although movable, 
its attachment is broad. Careful inspection will usually en- 



DIAGNOSIS AND PROGNOSIS. 419 

able us to make out that its surface is continuous with the 
supero-posterior canal wall, thus establishing its identity. The 
mass is exquisitely tender to pressure. Very little discharge 
is present, but the surface of the drum membrane and the ad- 
jacent walls of the canal are the seat of a desquamative pro- 
cess, and upon removing the epithelium, considerable serous 
transudation may take place, rendering exact diagnosis diffi- 
cult. Inflation with the catheter or air bag reveals no per- 
foration sound, the impact of the current being perceived as 
a dull, distant percussion sound, occasionally accompanied by 
bubbling rales. The conditions with which this may be con- 
founded are the presence of exuberant granulations, from 
which we have already given the means of differentiation, and 
a circumscribed external otitis. This latter condition, we 
remember, usually affects the fibrocartilaginous meatus, and 
after the speculum has once passed the orifice of the canal, 
the lumen appears of normal size. It may occasionally be 
mistaken for a diffuse external otitis, but here the canal is 
uniformly narrowed, the deeper portion of the postero-supe- 
rior wall being affected no more prominently than its entire 
length. Tenderness over the mastoid region denotes an in- 
volvement of the pneumatic spaces, but a much better sign is 
the appearance already described in the canal. When, there- 
fore, the appearance is indicative of a circumscribed otitis of 
the deep canal, we are to remember that this condition is 
almost pathognomonic of mastoid involvement, and are to 
proceed to treat the mastoid inflammation without delay. 

Prognosis. — The cases in w^hich discharge alone is the 
symptom almost invariably terminate favorably, often without 
treatment. If neglected, infection may take place, and a 
chronic purulent condition supervene. The occurrence of 
one attack probably renders the patient more prone to a simi- 
lar process in future. In the cases attended by pain the 
condition is practically one of cellulitis, and should never be 
considered lightly. If left to itself, it may resolve spontane- 
ously, or the fluid may escape into the atrium and then into 
the canal, or rupture may take place through the superior 
segment of the drum membrane. If spontaneous resolution 
does not take place, evacuation in either manner mentioned 
above seldom occurs before the bony parts are seriously in- 
volved, and a permanent discharge is a frequent outcome. 
If discharge does not take place, involvement of the mastoid 



4 20 OTITIS MEDIA PURULENTA RESIDUA. 

cells or an extension to the intracranial contents, either by 
rupture or by infection through the venous channels, may 
occur. Concerning- the effect upon audition, there is little 
danger that the function of the organ will be changed by such 
an intercurrent attack, the degree of impairment which was 
formerly present persisting but suffering no aggravation. 

Treatment. — For the relief of the discharge, attention to 
cleanliness is all that is necessary. Irrigation with a mild 
solution of any of the well-known antiseptics, repeated as 
frequently as may be necessary to keep the canal free of dis- 
charge, is usually the only treatment required. This measure, 
in addition to cleansing the parts, causes a certain amount of 
depletion, which hastens resolution. In order that no secre- 
tion may remain in the middle ear, it is well to inflate by 
means of the air bag or by the Valsalva method before irriga- 
tion. In the early stages remedies directed toward stopping 
the discharge are contraindicated. When the more acute 
symptoms have passed away, if the discharge continues, we 
may follow each irrigation by the instillation of a solution of 
boric acid in alcohol in the proportion of twenty grains to 
the ounce, or a i-to-3,000 solution of the bichloride of mercury 
dissolved in equal parts of alcohol, and water may be em- 
ployed in the same manner. Occasional applications of me- 
tallic astringents — such as solutions of nitrate of silver, from 
two to twelve per cent — will frequently hasten the return to 
the normal condition. Where the discharge is small in 
amount but fails to cease entirely, we may discontinue irri- 
gation altogether and rely upon insufflation of powders. Of 
these, nothing is better than boric acid, either alone or with 
the addition of iodoform, alum, iodol, etc. In making appli- 
cations of this character, but a small quantity of the powder 
should be used, to avoid mechanical obstruction to any fluid 
which may be transuded. 

If, in spite of intelligent treatment, the discharge contin- 
ues, we are warranted in the supposition that the osseous 
structures have become involved, and relief will follow only 
the removal of the diseased bone. To guard against recur- 
rent attacks, attention to the upper air passages is of the 
greatest importance. These recurrent cases usually occur in 
children under fifteen years of age, and in many instances we 
find that the vault of the pharynx contains an excessive 
amount of lymphatic tissue, while the faucial tonsils may 



TREATMENT. 



421 



also be hypertrophied. These conditions call for operative 
treatment, or topical applications, as may seem best adapted 
to the particular case. Any obstructive lesion in the nasal 
passages must also be overcome by operative or other 
methods. 

Where the upper portion of the tympanic cavity is the 
seat of the process, the first indication is to relieve the pain, 
and at the same time to abort the local condition ; or, if too 
far advanced for this, to evacuate the products of inflamma- 
tion. To effect the first object, the patient should be put to 
bed and a full dose of opium or morphine administered, while 
at the same time local depletion should be employed. Un- 
doubtedly the best method of attaining this end is a free in- 
cision through the upper part of the membrana tympani 
behind the short process of the malleus. This incision should 
extend from the last-named point backward to the canal wall, 
and may be continued outward upon its surface for from a 
sixteenth to a quarter of an inch; this I believe should be 
done whether any bulging is present or not. If fluid has al- 
ready been effused and there are evidences of obstruction to 
its free discharge, the procedure is imperatively demanded. 
If this stage has not been reached, the local depletion will 
probably check its progress. If it does not seem advisable 
to incise the parts, the application of natural leeches or of 
the artificial leech in front of the tragus, removing from one 
to two ounces of blood, according to the age and condition 
of the patient, is the procedure to be employed. The appli- 
cation of cold to the mastoid is proper if there is the least 
suggestion of swelling along the posterior wall of the canal ; 
irrigation of the parts with warm aseptic or antiseptic solu- 
tions should be begun at once, whether an incision has been 
made or not. If this has been done it will favor the haemor- 
rhage and render our efforts at aborting the attack more cer- 
tain, while if no surgical measures have been instituted the 
combined effect of heat and moisture may so reduce the 
tumefaction as to permit the discharge of the fluid products 
through the atrium, or may possibly lead to resolution with- 
out the supervention of discharge. The internal adminis- 
tration of analgesics is contraindicated after the first twenty, 
four or thirty-six hours, as it serves only to mask the symp- 
toms. If relief is not obtained at the end of this time, and 
surgical measures have been delayed, they must now be in- 



422 OTITIS MEDIA PURULENTA RESIDUA. 

sisted upon, and a free section of the tissues involved must 
be made. The use of the ice coil should not be persisted in 
for more than forty-eight hours ; if, in spite of its use, the 
pain continues severe and the mastoid is tender upon pres- 
sure, or even if there is no tenderness, if the postero-superior 
wall is depressed, the process has almost certainly extended 
to the pneumatic spaces of this structure, and operation 
should not be delayed. Regarding the value of Wilde's in- 
cision in these cases, I can only say that I never employ the 
measure. If the symptoms do not seem prominent enough 
to warrant the opening of the mastoid, incision of the over- 
lying parts on its anterior surface, which forms the posterior 
and superior walls of the meatus, is the measure which will 
most probably give relief. It certainly possesses all the bene- 
fits of the external incision, both as regards the relief of ten- 
sion and depletion, and may very properly be employed as a 
last resort before opening the mastoid process. In this class 
of cases I think we can not too strongly insist upon an early 
mastoid operation if the symptoms do not disappear promptly. 
The advantages of this are not only the immediate relief to 
the present condition, but also the certainty with which a 
subsequent chronic purulent otitis media is prevented. Un- 
less checked by radical measures, the affection is almost cer- 
tain to be followed by a chronic otorrhcea, although the pres- 
ent attack may be recovered from. Where an operation is 
performed early we usually avoid this, and the period of con- 
valescence is much shortened. Another advantage is that 
recurrence is decidedly uncommon in cases operated upon, 
whereas those cases which recover without operation are 
specially prone to recurrence of the condition. Operations 
to obtain drainage through the meatus can not be advised ; 
no doubt in some instances they are successful, but the en- 
gorgement of the parts is so great that the haemorrhage must 
be considerable, and in the narrow field of operation this pre- 
sents an almost insurmountable obstacle. 

2. Chronic Type. 

Under this term is comprised those cases whose symp- 
toms depend upon the changes which have taken place as the 
result of persistent inflammation. These either remain con- 
stant or increase very slowly, according as the connective 
tissue developed as a result of the pathological condition is 



CHRONIC TYPE: ITS PATHOLOGY. 



423 



in a perfectly quiescent condition, or is slowly undergoing 
secondary sclerotic changes. The condition is comprised 
under the general term " rigidity of the ossicular chain," and 
the affection is by some authors denominated as " otitis media 
sclerotica." Owing to the increase in fibrous tissue within 
the middle ear, the entire ossicular chain is carried inward 
toward the internal wall ; the foot plate of the stapes is 
crowded into the oval window, causing an increase in laby- 
rinthine pressure, while at the same time the outward move- 
ment of the membrana tympani secondaria is impeded 
through a process of a similar character in this region. We 
have, then, the labyrinthine fluid subjected to a permanent 
increase in pressure. No doubt the equilibrium is partially 
restored by the passage of the fluid through the channels 
communicating with the subdural lymph spaces. Where the 
increase of pressure is but moderate in amount this may so 
far compensate for the inward movement of the stapes as to 
render the condition of equilibrium practically perfect, in 
which case no symptoms arise. More frequently the in- 
creased tension persists, producing in the early stages the 
symptoms characteristic of acute labyrinthine pressure, while 
at a later period evidences of atrophy of the terminal fila- 
ments of the auditory nerve manifest themselves, the con- 
tinued pressure destroying these structures. 

Pathology. — Following the same general classification of 
gross pathological appearances already described in treating 
of chronic purulent otitis media, it is not difficult to under- 
stand how in each individual class the action of the conduct- 
ing chain in response to aerial vibrations is seriously inter- 
fered with. We may classify the interference with sound 
transmission in these cases as due to — 

1. Simple oedema of the mucous membrane. 

2. The presence of localized areas of hypertrophy due to 
chronic inflammation. 

3. Adhesions either between the various members of the 
ossicular chain or between the malleus and incus and the in- 
ternal tympanic wall. 

4. Cicatricial bands in the membrana tympani. The mem- 
brana tympani itself may, as the result of a chronic inflam- 
mation, press the entire ossicular chain inward. This is spe- 
cially true of cases in which a large portion of the membrane 
has been destroyed and the margin of the perforation coin- 



424 



OTITIS MEDIA PURULENTA RESIDUA. 



cides with the posterior fold. A dense band frequently de- 
velops here, which crowds either the stapes or incus inward, 
causing- serious impairment of function. 

5 Adhesions limited to the region of the stapes. These 
adhesions develop either between the foot plate and the oval 
window, or between the crura and the walls of the pelvis 
ovalis, or from dense bands about the tendon of the stapedius 
muscle. 

This classification, it is understood, is merely general; any 
of the conditions may exist singly, or several may be pres- 
ent in the same case. In general it may be said that the im- 
pairment in hearing and tinnitus undergo but little change 
in those cases where the functional disturbance is due to a 
deposit of new connective tissue either in the remnant of the 
membrana tympani or between the various ossicula them- 
selves, or between the ossicles and the tympanic walls. 
Where the drum membrane is destroyed over a large area 
and the lining of the tympanic cavity is exposed, the power 
of audition frequently varies considerably at different times. 
Such changes usually depend upon congestion of the lining 
of the middle ear, or upon an accumulation of inspissated 
secretion in the deeper portions of the canal. In many of 

these cases, although there is 
apparently no discharge, the mu- 
cous membrane has not under- 
gone complete dermoid trans- 
formation, and consequently 
continues to pour out a small 
amount of secretion. This be- 
comes inspissated and collects 
most frequently in the upper 
and posterior quadrant directly 
over the stapes, and sometimes 
seriously interferes with the 
movements of the ossicle (Fig. 
115). Those cases which suffer 
from frequently recurring at- 
tacks of congestion of the lining 
membrane of the middle ear 
with the production of a slight amount of discharge are prone 
to suffer from the development of exuberant granulations in 
the various portions of the tympanic cavity. This is particu- 




FlG. 115. — Inspissated secretion mixed 
with cerumen, covering a small 
perforation in the supero-posterior 
quadrant (natural size). 



SYMPTOMATOLOGY. 



42 5 



larly true where proper attention is not paid to cleanliness, 
the continued action of heat and moisture favoring the devel- 
opment of exuberant granulations. 

Symptomatology. — The symptoms to which these changes 
give rise consist usually in an impairment of function of the 
organ, either to a considerable extent or only to a slight de- 
gree. As we have said before, impairment in hearing follow- 
ing purulent inflammation is less marked than when it occurs 
as the result of a nonsuppurative inflammation. The pres- 
ence of subjective noises is not a symptom of as much im- 
portance in these cases, as they are seldom so prominent as 
to give serious discomfort, and unless specially inquired into 
may not be mentioned by the patient himself. Attacks of 
giddiness are occasionally complained of, usually following 
some manipulation about the ear, such as the insertion of 
some instrument into the canal for cleansing it, or the use of 
the syringe. In these instances we usually find that the head 
of the stapes is exposed. From the above classification of 
the affection we are now considering no discharge is present 
in these cases. The canal, however, is seldom perfectly free 
from foreign material. The exposed mucous membrane ex- 
foliates its superficial epithelium, which accumulates within 
the meatus, or adheres to the walls as thin yellowish-white 
or brownish scales. These masses frequently adhere quite 
firmly to the walls of the meatus, and upon separating them 
a denuded area remains. The presence of this desquamated 
material, together with the moisture normally present in the 
canal, favors the development of the various forms of asper- 
gillus, causing a slight discharge, or in severe cases an acute 
external otitis, with the attendant symptoms of pain, etc. 
The hearing is usually fairly constant, any variation from 
this condition being coincident with congestive changes in 
the upper air passages, as when the individual suffers from 
an acute coryza or from an acute naso-pharyngitis. 

The development of cholesteatoma may manifest itself in 
cases which have remained quiescent for a long period. In 
certain cases the superficial epithelium of the canal migrates 
into the tympanic cavity and replaces the pavement epithelium 
of the mucous membrane. These epidermal cells are devel- 
oped with unusual rapidity and as quickly thrown off. As 
the result, the tympanum is filled with a mass of epithelial 
cells which steadily increases in size and exerts great pressure 



426 OTITIS MEDIA PURULENTA RESIDUA. 

upon the surrounding bony walls. The mastoid cells at a 
later period are invaded. The partitions between the pneu- 
matic spaces are broken down, converting this series of small 
cavities into one large cavity. 

Such a mass may produce no distinctive symptoms until 
the tympanum becomes acutely inflamed from some cause, 
when the sudden increase in volume due to the absorption 
of the products of the inflammatory process induces acute 
symptoms referable to the mastoid or middle ear. 

Where a suppurative inflammation has existed for a long 
time a condensing osteitis of the mastoid not uncommonly 
occurs. This may continue after suppuration in the tym- 
panum has ceased. The mastoid then becomes the seat of in- 
tense pain, either constant or paroxysmal, while neither the 
mastoid nor middle ear presents any evidence of acute inflam- 
mation. The possibility of such a process should always be 
borne in mind when persistent neuralgia of the mastoid region 
is met with in a subject who has suffered from a purulent 
otitis at any previous period. 

In this connection it might be mentioned that in any case 
of persistent facial neuralgia of obscure origin the ear should 
always be examined. I have found in cases coming under 
observation for some aural affection, that frequently the treat- 
ment of the ear has arrested the attack of facial neuralgia, and 
the patients have of their own accord asseverated the facts. 

It should be remembered that a suppurative inflammation 
in early infancy may leave no evidence in adult life except a 
minute pit or opening above the short process of the malleus. 
In these cases in particular the remains of the former affec- 
tion may produce the symptoms in question. 

Diagnosis. — A. Physical Examination. — The condition, as 
revealed by an examination of the parts, is of but little serv- 
ice in estimating the degree of impairment of hearing, or 
the relation between this impairment and the trouble present 
in the middle ear. It is only by a thorough functional exami- 
nation in connection with minute ocular inspection that w 7 e 
can correctly judge as to how much of the interference with 
function depends upon the changes within the tympanum, as 
distinguished from that caused by the labyrinthine involve- 
ment. 

B. Functional Examination. — Where the middle ear alone 
is affected, the examination by means of musical tones and 



FUNCTIONAL EXAMINATION AND PROGNOSIS. 



427 



the ordinary tests for hearing yields results characteristic of 
obstruction to sound conduction. These are elevation of the 
lower tone limit, very slight lowering of the upper tone limit, 
or no deviation from the normal standard, increased bone 
conduction, and, if one side alone is affected, a lateralization to 
the affected side of the vibrating tuning fork held upon the 
forehead in the median line. Moreover, the impairment is 
usually relatively greater for the voice than for sharp sounds, 
such as those of the watch or acoumeter. The degree of 
impairment for spoken or whispered words is proportionate 
to the height, in the musical scale, to which the relative dura- 
tion of air and bone conduction is reversed, the inversion 
extending to the upper notes when the degree of impairment 
is marked, but affecting only the lower portion of the scale 
when this impairment is but moderate. 

When the labyrinth has become involved we have, in ad- 
dition to the evidences of interference with sound conduction, 
certain signs characteristic of changes in the lower portion of 
the cochlea. The upper tone limit is almost invariably low- 
ered to a marked extent, usually below 20,000 V. S. Where 
the elevation of the lower tone limit remains the same as in 
uncomplicated cases, absolute bone conduction is usually 
diminished, and this is always the case when serious labyrin- 
thine involvement is present. Occasionally it may be normal 
or increased. The tuning fork held upon the vertex is sel- 
dom lateralized to the poorer ear. The important diagnostic 
test is an observation of the relation between the impairment 
for whispered or spoken words and the position in the musi- 
cal scale at which the reversal between air and bone conduc- 
tion ceases. It will be found that where impairment is due 
chiefly to labyrinthine changes the impairment of hearing 
will be very marked, while the ratio between air and bone 
conduction will be reversed only for the very lowest notes. 
In such instances, even if the abnormal tension in the sound- 
conducting mechanism can be corrected, sufficient changes 
have taken place in the perceptive apparatus to render these 
measures of but little value in improving the hearing. 

Prognosis. — The disease under discussion is usually more 
amenable to treatment than any other form of chronic tym- 
panic inflammation. If left to itself, the majority of cases 
either do not progress at all, or deterioration is so slow as to 
enable us to promise that it will cause but little increased in- 



428 OTITIS MEDIA PURULENTA RESIDUA. 

convenience in the future. A certain proportion of these 
cases improve spontaneously. This is particularly true in 
children or young adults, the continued massage of the parts 
by the sonorous vibrations to which they are subjected 
gradually stretching the adhesions or causing their resorp- 
tion. After the age of thirty or thirty-five this probably never 
takes place spontaneously. After proper treatment the con- 
dition seldom recurs, and any improvement is likely to be 
permanent, it being more probable that the condition will 
even improve in subsequent years. The degree of improve- 
ment to be attained depends more upon the degree of laby- 
rinthine involvement than upon any other one circumstance. 
If this is considerable, measures directed toward the middle 
ear probably aggravate the condition rather than benefit it. 
This is specially true of surgical measures. Certain cases 
come under observation on account of a sudden impairment 
of audition, and examination may reveal serious interference 
with the labyrinth. Where these changes are recent, meas- 
ures directed to the middle ear are not contraindicated, since 
the disturbance within the labyrinth may depend upon some 
recent change in the sound-conducting mechanism which has 
not advanced to such an extent as to render the removal of 
the cause ineffectual in relieving the condition. 

Treatment. — Where the symptoms depend upon swelling 
of the mucous membrane, measures directed toward the regu- 
lation of the habits of life especially are among the first indi- 
cations. Next, the condition of the upper air passages should 
be thoroughly investigated and any obstructive condition 
corrected. This is particularly true where functional exami- 
nation indicates labyrinthine interference, on account of the 
intimate relation between the venous return current from the 
labyrinth and that from the nasal passages. If these meas- 
ures are not successful, topical applications to the lining 
membrane of the middle ear are to be instituted. These 
should be of mildly astringent character at first, the strength 
being increased if necessary. It is interesting in this connec- 
tion to remark that although the membrana tympani may be 
almost completely destroyed, a restoration of the lumen of 
the Eustachian tube to its normal calibre will frequently re- 
lieve the symptoms. This depends, no doubt, upon the re- 
moval of obstruction to the venous return current from the 
tympanum. The condition within the Eustachian tube either 



TREATMENT. 429 

may yield to simple inflation or may demand the use of some 
stimulating vapors, and in the more severe cases it may be 
necessary to resort to the bougie. 

We should never lose sight of one fact, and that is the ex- 
treme susceptibility of these cases to the development of one 
of the vegetable molds. This may keep up a chronic conges- 
tion of the lining membrane of the middle ear in spite of the 
treatment already mentioned, and we should always be cer- 
tain that the meatus is in a fairly aseptic condition in order 
that this factor may be eliminated. Where hypertrophic 
changes are more extensive and small aggregations of newly- 
formed tissue are found in any locality, these may be de- 
stroyed in situ either by the potential cautery or by chemical 
agents, but they are seldom large enough to be removed by 
means of the curette or snare. Occasionally a small crust 
will develop in the upper posterior quadrant, directly over 
the region of the oval or round windows, preventing the 
transmission of aerial vibrations to the labyrinthine fluid. 
Such an obstruction may be removed by the forceps, curette 
or syringe, as seems indicated in the particular case. It 
should be remembered that the removal of such a mass may 
be followed by a recurrence of the discharge, and it is wise 
to mention this fact to the patient before operating. 

Where the tense margin of a remnant of the membrana 
tympani displaces the ossicles in any manner, the division 
of the fold by means of the knife is frequently followed by an 
astonishing improvement in function. The section can be 
made under cocaine anaesthesia, and if proper aseptic precau- 
tions are observed in preparing the field of operation, the pro- 
cedure is followed by no discomfort. It is frequently neces- 
sary to repeat the section several times, the parts reuniting 
after division. They do not, however, unite throughout the 
entire length of the incision, and by repeating the procedure 
the tension is gradually relieved. When an obstructing band 
can not be exactly located in those cases where the entire 
ossicular chain remains, and other measures have failed to 
effect the desired improvement, it is wise to remove the re- 
mains of the membrana tympani, together, with the two 
larger ossicles, thus exposing the round window and the 
stapes, the latter ossicle being dealt with according to the 
condition found upon inspection. This plan is advocated 
after considerable practical experience in cases of this char- 



43Q 



OTITIS MEDIA PURULENTA RESIDUA. 



acter ; and although relief is sometimes obtained by dividing 
rather blindly various constricting bands which lie beyond 
the field of vision, but are known to be present from the posi- 
tion which the ossicles assume, we seldom obtain sufficient 
amelioration to be satisfactory either to the surgeon or to the 
patient, and at length resort to the more complete opera- 
tion already mentioned. It is wise, therefore, to make this 
the operation of election, and to eliminate thoroughly all 
interference with tension in the conducting chain at a single 
operation. 

Where the stapes is exposed, the incudo-stapedial articula- 
tion having been destroyed, several plans of treatment are 
open to us. The simplest is auto-mobilization, by inserting 
an artificial drum membrane, such as a small disk of paper or 
a small pledget of cotton. This is applied with the forceps 
or cotton holder, so as to rest upon the head of the stapes, and, 
by increasing the surface presented for the reception of aerial 
vibrations, causes them to exert a more powerful force upon 
the stapes. Decided improvement has followed this plan in 
several cases. Where manipulation by means of the probe 
shows that the stapes is firmly fixed, it is well to break up 
these adhesions by manipulation, the knife being employed to 
divide the more dense bands if necessary. The technique of 
these operations will be described in a chapter devoted to 
the operative surgery of the middle ear. 

Concerning the advisability of the extraction of the stapes 
good results have been obtained in these residuary cases. It 
is a question in my mind, however, whether we can not obtain 
similar, or even better, results by leaving the stapes in place 
and mobilizing it mechanically ; for, although I have removed 
it a number of times with good results, I have, in cases pre- 
senting similar symptoms arid responding in the same manner 
to functional tests, seen no improvement whatever follow the 
operation. If the entire stapes can be removed, it can cer- 
tainly be mobilized, and the foot plate probably transmits the 
sonorous waves to the labyrinth more perfectly than does the 
cicatricial membrane which is formed after its removal. 
Where ossification at the stapedio-vestibular articulation has 
taken place, the removal of the part piecemeal may be at- 
tempted. This procedure is effected either by means of a 
sharp spoon or by a small burr, which wears away the thin, 
bony lamella separating the labyrinth from the tympanum. 



TREATMENT. 



431 



The burr should be conical in shape and so guarded as to 
prevent its entering the labyrinth more than a millimetre, 
when the foot plate is perforated. 

Adhesions about the round window can seldom be seen, 
but their presence may be suspected when the niche of the 
fenestra rotunda is surrounded by hypertrophied mucous 
membrane. Stellate incision, by means of an angular knife 
inserted into the niche, will relieve tension here, and is fre- 
quently followed by improvement in connection with opera- 
tive procedures about the oval window. Concerning any 
aggravation of symptoms which surgical measures may in- 
duce, I can only say that their occurrence is very rare, if we 
bear in mind the rule that when serious labyrinthine disturb- 
ance is present operative measures are contraindicated. 

Where the labyrinth is involved the internal administra- 
tion of pilocarpine often relieves the tension and is followed 
by an amelioration of the symptoms. After this has occurred, 
if functional examination indicates that the tympanic lesion is 
a competent cause of the interference with function, opera- 
tive measures now become proper. Where the residual con- 
dition is present in but one ear, the effect upon the organ of 
the opposite side is always to be borne in mind. If the oppo- 
site ear becomes affected, the changes first met with are usu- 
ally labyrinthine in character, and operative measures may be 
indicated for the preservation of the sound organ, although the 
ear operated upon may be beyond relief. It is sometimes 
stated that interference in these residuary cases may be fol- 
lowed by a recurrence of the discharge, but it has never been 
my experience to witness this. A discharge from an ear 
which is the seat of a residual process can depend only upon 
the presence of some foreign body ; and no operative meas- 
ures, if properly carried out, would lead to the development 
of this condition — that is, to the development of bony ne- 
crosis. 



IV. DISEASES OF THE MASTOID PROCESS. 



CHAPTER XXIV. 



THE ANATOMY OF THE MASTOID PROCESS. 



In considering the anatomy of the ear a detailed descrip- 
tion of the mastoid process was not given, it seeming wiser 
to incorporate the necessary details in the section on Diseases 
of the Mastoid. The mastoid portion of the temporal bone 
is an irregular conical mass of osseous tissue located behind 
the external auditory meatus and projecting for a varying 
distance below the level of its floor. Its lower extremity, 
forming the apex of the cone, is covered by the aponeurosis 

of the sterno-mastoid 
muscle. This muscle 
is attached not only to 
the tip of the process, 
but also for a consider- 
able distance along its 
internal aspect. Above 
the insertion of the 
muscle upon the inter- 
nal surface of the mas- 

Fig. 116. — The pneumatic mastoid. The section 

shows the relative position of the tympanic vault toid is a deep furrow, 

and mastoid antrum to each other and to the f i rlirvocfnV frrAA ,.„ 

intracranial surface. (Author's specimen.) me Cllgasmc groove, 

which lodges the oc- 
cipital artery and furnishes attachment for the posterior head 
of the digastric muscle. This bony mass may be pneumatic, 
diploic, or sclerotic in structure. In the pneumatic mastoid 
(Fig. 1 16) there are numerous air spaces throughout the entire 
mass ; these are irregularly distributed, in some cases lying 
almost immediately below the cortex, while in other instances 
they are situated at considerable depth below the outer sur- 
face of the bone and are specially numerous upon its anterior 
aspect ; this anterior wall of the mastoid forms the posterior 

(432) 





VARIATIONS IN STRUCTURE. 433 

wall of the external auditory canal, and when the cells are 
well developed in this region the earliest evidences of their 
involvement in an inflammatory process appears here. One 
pneumatic space is constant, and that is the antrum. This cav- 
ity is irregularly pyramidal in shape, communicates with the 
tympanic vault by a narrow passage, and varies considerably 
in size in different individuals. At birth the antrum is the 
only space developed, the others being formed subsequently. 
We not infrequently find a second cell of considerable size 
located at the very tip 
of the process ; the out- 
er bony wall of this 
space is often very thin 
— a fact which is of con- 
siderable clinical im- 
portance. 

In the diploic mas- 
toid the antrum alone w j 
is present, the remain- ^ ^ ^. , 

. . Fig. 117. — Diploic mastoid. 

ing portion consisting 

of diploic tissue, similar to that found in the other cranial 

bones (Fig. 117). 

Where the mastoid is sclerotic the entire process consists 
of a dense eburnated mass of osseous tissue ; its structure is 
uniform throughout, presenting not even the slightest vestige 
of a pneumatic space, with the exception of the antrum, and 
even this may be of small size. 

Various combinations of these three forms may be met 
with in individual cases ; thus a sclerotic process may have 
progressed to a certain point and ceased spontaneously, in 
which event the trabecular will be firmer than normal and 
the pneumatic spaces of small size ; or but one or two air 
cells may exist, the remaining portion being diploic in struc- 
ture. 

Owing to the invariable presence of the mastoid antrum, 
its location is a matter of importance. It is best located by 
bearing in mind its relation to the superior and posterior walls 
of the external auditory meatus. If two lines be drawn — one 
horizontal, tangent to the superior wall of the external audi- 
tory canal, the second vertical and tangent to its posterior 
wall — the point of their intersection will be the apex of a tri- 
angle the base of which will be formed by that portion of the 
29 



434 



THE ANATOMY OF THE MASTOID PROCESS. 




Fig. 118. — Horizontal section through a pneu- 
matic mastoid, s, Groove for lateral sinus ; 
a. Mastoid antrum ; t, Tympanic cavity ; g, 
Posterior wall of external canal ; w, w', Path 
of instrument from surface of mastoid to 
antrum. (Politzer.) 



curvilinear outline of the meatus included between the points 
of tangency of these lines. This triangle lies immediately 

over the antrum and an 
artificial opening within 
this space will enter the 
cavity. 

Another cell which 
is fairly constant is that 
large pneumatic space 
located at the tip of the 
apophysis. The outer 
bony wall of this cavity 
on the digastric surface 
of the mastoid is often 
no thicker than parch- 
ment, and where the mas- 
toid is the seat of an in- 
flammatory process at- 
tended by the formation 
of pus, the involvement of this large space may be first evi- 
denced by the presence of diffuse tumefaction near the mastoid 
origin of the sterno-mastoid muscle, either on the external sur- 
face or more usually in the digastric fossa, in which case the 
tumefaction lies immediately beneath the body of the muscle. 

The relation which the mas- 
toid bears to the intracranial 
contents is of importance in the 
performance of surgical opera- 
tions in this region. The to- 
pographical relations between 
the mastoid and the tympanum 
and cranial fossae are best con- 
sidered together, since operative 
procedures upon the mastoid 
process are usually demanded 
because of some abnormal con- 
dition within the tympanum, 
and this cavity is always entered 
at the time of operation. The 
roof of the tympanum is formed by the petro-squamous suture 
and supports the temporo-sphenoidal lobe of the cerebrum. 
The vault of the tympanum and mastoid antrum, then, are in 




■g 

Fig. 119. — a, Mastoid antrum; s, 
Groove for lateral sinus ; g, Pos- 
terior wall of external canal ; w, w ', 
Path of instrument from surface of 
mastoid to antrum. (Politzer.) 



RELATIONS WITH THE CRANIAL CONTENTS. 



435 



relation above to the middle cranial fossa ; hence any product 
of inflammation passing through the roof of the tympanum 
enters this portion of the cranial cavity, after which its con- 
veyance along the superior surface of the petrous portion of 
the temporal bone to the region of the medulla is exceedingly 
simple. As the mastoid antrum is but an extension backward 
of the vault of the tympanum, its intracranial relations are 
the same as are those of the tympanic vault. The mastoid 
cells are also in relation with the meninges of the posterior 
cerebral and the cerebellar fossae. In cases of intracranial 
involvement complicating mastoid inflammation, the process 
is usually confined to meninges covering the posterior cere- 
bral lobe or the cerebellum. When extension takes place 
through the roof of the tympanum the contents of the middle 
cranial fossa is usually involved. 

The internal surface of the mastoid process presents a deep 
groove for the lodgment of the lateral sinus. The distance 
which this vessel may extend into the mastoid varies in indi- 
vidual cases ; usually it lies be- 
hind the antrum, and in some 
instances the bend of the sinus 
is so sharp that the acute angle 
extends forward so as to lie but 
a short distance behind the pos- 
terior wall of the external audi- 
tory meatus, and may be so near 
the surface of the process as to 
cover the antrum (see Fig. 120). 
It is evident that with the sinus 
in this position an artificial open- 
ing into the antrum could not 
be made at the site of election 
for entering this cavity without 
exposing or wounding this large 
venous channel. In Fig. 118 the parts are so placed that the 
sinus is in no danger, while in Fig. 119 it could be avoided 
with care. 

An examination of numerous specimens has been made 
by both Korner * and Randall f for the purpose of determin- 




Fig. 120. — t, Tympanic cavity ; u, 
Floor of external meatus ; s, Gioove 
for lateral sinus ; w, w', Path of in- 
strument from surface of mastoid to 
antrum. In this case the sinus would 
be wounded in the operation. (Po- 
litzer.) 



* Arch, of Otol., vol. xviii, p. 310. 

•}• Trans, of the Amer. Otol. Society, 1892, p. 235. 



436 THE ANATOMY OF THE MASTOID PROCESS. 

ing whether the location of the sinus could be positively de- 
cided by external measurements of the skull. These re- 
searches prove conclusively that external measurements are 
useless in determining the site of the sinus. This venous 
channel, then, bears an important relation to the mastoid pro- 
cess, and its variable situation must always be borne in mind 
in operative procedures. When, for any reason, it seems de- 
sirable to expose the sinus during an operation, it can be done 
by extending the opening in the bone backward, care being 
taken to avoid the removal of any bone beyond the occipito- 
temporal suture. The groove lodging the knee of the sinus 
is located in the mastoid process, and an extension of the open- 
ing to the point of junction between the occipital and temporal 
bones affords abundant space for examination of the sinus as 
well as of the condition of the posterior cranial fossa both 
above and below the tentorium. This statement regarding 
the extensive removal of bone in exposing the sinus may 
seem unnecessary, but where the patient is anaemic the ex- 
posed sinus may be nearly empty and its walls may be of the 
same color as the contiguous meningeal surface, rendering its 
recognition difficult. 

From the presence of this vessel it is advisable in all oper- 
ations upon the mastoid first to remove the cortex as close to 
the posterior wall of the canal as possible. After the cells 
are entered and the topography of the particular process is 
ascertained, the opening may then be enlarged as much as is 
necessary, but the cavity should always be entered as close 
to this line as possible. 

In the majority of cases the middle cranial fossa lies at a 
considerably higher level than the horizontal plane passing 
through the superior wall of the bony meatus. The location 
of the floor of this space is commonly above the plane pass- 
ing through the temporal ridge, this last term being applied 
to the prolongation of the roof of the zygoma backward 
over the entrance of the external auditory canal. The tem- 
poral ridge was for a time considered the upper limit of 
safety in opening the mastoid process. Occasionally, how- 
ever, we meet with cases in which the squamous portion of 
the temporal bone, instead of lying almost vertical, is consid- 
erably inclined, forming an acute angle with the horizontal 
plane. When this occurs the temporal ridge overhangs the 
entrance to the meatus (Fig. 121). Unless care is exercised, 



DEVELOPMENTAL CHANGES. 



437 




the superior margin of the canal will not be correctly located, 
the prominent ridge being mistaken for it. It will easily be 
seen that if the chisel is now applied over what seems to be 
the area ordinarily 
selected for perfo- 
rating the cortex, the 
opening will be situ- 
ated above the mas- 
toid antrum, and the 
middle cranial fossa 
will be entered. Care 
should be taken, 
therefore, to recog- 
nize this anomaly, 
and to be certain 
that the superior 
margin of the canal 
is really exposed be- 
fore the bone is per- 
forated. In young 
children this promi- 
nence of the tem- 
poral ridge is a usual 
condition, owing to 

the exceedingly oblique angle between the squama and the 
auditory plate (Figs. 6 and 122). 

In the infant at birth the mastoid is but poorly developed, 
consisting usually of but a single cell — the antrum. It must 
be remembered, however, that there is a very large pneumatic 
space in immediate relation to the tympanic cavity, as the 
vault of the tympanum in the child is nearly as large as in 
the adult, the ossicles increasing but little in size from the 
period of birth to adult life. This, no doubt, explains the 
cause of the pronounced symptoms found in even the simpler 
inflammations of the middle ear in infancy and early child- 
hood. The inner table of the cranium is excessively thin, 
and frequently incomplete in places along some of the sutural 
lines. The vascular supply of the lining membrane of this 
pneumatic space, made up of the vault of the tympanum 
and of the mastoid antrum, is very free and in close anasto- 
motic relation with the intracranial venous sinuses. For this 
reason symptoms of meningeal irritation are frequently ob- 



Fig. 121. — Adult temporal bone in which the tem- 
poral ridge overhangs the entrance to the canal. 
(Author's specimen.) 



433 



THE ANATOMY OF THE MASTOID PROCESS. 



served, even in a mild attack of otitis media in infancy. 
Again, a fatal termination is probably more common than we 
are aware, due to an early thrombosis of the venous sinuses, 
or to septic meningitis. These may occur even before dis- 
charge appears in the external auditory meatus, and perhaps 
without special attention having been called to the ear, unless 
the physician is aware of the fact that one of the most fre- 
quent causes of high temperature in young infants is a middle- 
ear inflammation. A reference to Fig. 122, which is a draw- 
ing of a specimen in the posses- 
sion of the author, shows how 
capacious this pneumatic space 
may be at birth. 

The depth at which the mas- 
toid antrum lies varies in differ- 
ent cases. It is seldom entered 
at a depth of less than half an 
inch, and may lie seven eighths 
of an inch below the external 
surface. The only structure of 
importance lying within the mas- 
toid process itself is the facial 
nerve, which passes out through 
the stylomastoid foramen. The 
nerve crosses the upper portion 
of the tympanic cavity in the 
aquaeductus Fallopii, and leaves 
the cavity through an opening 
in the posterior wall. In the mastoid its course is downward, 
outward, and slightly backward, crossing the line of the pos- 
terior canal wall at the junction of the lower and middle 
third. Since it is deeply placed and the bony wall covering 
it is so dense, it is seldom wounded, and a little care will 
enable the operator to avoid it. Immediately above the 
aquaeductus Fallopii we find the horizontal semicircular canal. 
This structure can be injured only by continuing the artificial 
opening beyond the level of the internal wall of the tym- 
panum, an accident which need not occur if ordinary care is 
exercised. The same may be said of wounding the facial 
nerve in its passage through the aqueduct. 




Fig. 122. — The tympanic vault and 
mastoid antrum at birth, a, Ex- 
ternal canal separated from sur- 
face of squama. At its inner 
extremity is the membrana tym- 
pani inclosed by the tympanic 
ring. Above the ring the mal- 
leus and incus are plainly seen. 
(Author's specimen, natural size.) 



CHAPTER XXV. 

INFLAMMATION OF THE MASTOID PROCESS. 

^Etiology. — The most common cause of an acute inflam- 
mation in this region is an extension of a similar process from 
the middle ear. The primary lesion may be either acute or 
chronic in character, although it is probable that a simple 
catarrhal inflammation does not involve the mastoid process 
by extension. In cases where the mastoid is involved, during 
the course of what has seemed to be a catarrhal inflammation, 
it is believed that the process within the middle ear has al- 
ready changed in character and that the involvement of the 
mastoid has occurred at a very early stage on account of the 
intensity of the process, which has attacked not only the mid- 
dle ear, but the communicating pneumatic chamber as well. 

Primary mastoiditis, although uncommon, is occasionally 
seen, and may follow an exposure to cold or a traumatism, or 
may be a manifestation of a tubercular or specific diathesis. 
This last condition is probably the most common cause of a 
primary mastoid inflammation, a gummatous deposit occur- 
ring and subsequently breaking down in the characteristic 
manner. Inflammatory conditions within the meatus may also 
extend to the mastoid by contiguity. A simple circumscribed 
inflammation may produce this result, especially when located 
upon the posterior wall of the canal. Diffuse external otitis 
may cause a similar condition. Chronic suppurative inflam- 
mation of the middle ear is the most common cause of an 
acute mastoiditis. It seems curious that, from the intimate 
relation which exists between the mastoid cells and the tym- 
panum, the latter cavity may be the seat of a purulent in- 
flammation for years without producing a similar condition 
within the mastoid. From some slight cause, frequently so 
trivial in character as to be unrecognized, infection in this 
region occurs, terminating in extensive destruction of the 
osseous tissue. 

(439) 



440 INFLAMMATION OF THE MASTOID PROCESS. 

Pathology. — A chronic purulent otitis media causes cer- 
tain changes within the mastoid, attended by a thickening of 
the membrane lining the cells and an increase in the vascu- 
larity. These changes, continuing, lead to a deposit of new 
osseous tissue, which, in the most marked cases, converts the 
entire process into a mass of compact bone of ivorylike con- 
sistence and obliterates the cells completely. 

Again, instead of a hypertrophic change, a local necrosis 
may result. If this affects a large area, a sequestrum is formed, 
which is either exfoliated spontaneously or demands operative 
measures for its removal. If the destruction takes place over 
but a limited area, the disintegrated tissue is discharged as 
pus ; when moderate in amount and a free exit is afforded 
through the external auditory canal, the copious discharge 
from the canal may be the sole evidence of the involvement 
of the mastoid cells. If, however, drainage is not free, symp- 
toms of pus retention are manifested. 

The presence of infectious material within the bony cavity 
may produce several results ; the simplest, already mentioned, 
is a copious otorrhcea. If drainage through the canal is im- 
peded, the fluid must find exit, and evacuates itself spontane- 
ously where the least resistance is offered. This may be — 

i. Through the external mastoid cortex, either behind the 
ear or in the external meatus. 

2. Through the cortex in the digastric fossa. 

3. Through the roof of the antrum, or of the tympanic 
vault, into the middle cranial fossa. 

4. Into the posterior cranial fossa, usually by rupture into 
the groove lodging the lateral sinus. 

When the cranial cavity is invaded we have an inflamma- 
tion of the meninges, which may be diffuse or circumscribed. 
In the former condition a purulent leptomeningitis results, 
while in the latter an epidural abscess is formed. The pro- 
duction of an epidural abscess seems to be an effort on the 
part of Nature to limit the inflammation to a circumscribed 
area, the infectious material being walled in on all sides by 
adhesions between the dura and the adjacent osseous walls. 
Internal rupture is not the only manner in which the contents 
of the cranial cavity may be invaded ; the free anastomosis 
between the blood vessels of the dura and the pericranium 
may furnish the avenue through which the infectious material 
may pass to the intracranial contents. In this manner we 



INTRACRANIAL COMPLICATIONS. 441 

may have, in addition to the two conditions already men- 
tioned, a thrombosis of the lateral sinus, or an abscess within 
the brain substance. Unfortunately for the patient, these 
lesions, instead of being single, frequently occur together ; 
thus a sinus thrombosis without considerable meningitis is 
rare, while a brain abscess is a not infrequent accompaniment 
of thrombosis of the sinus. 

Where rupture takes place upon the external surface of 
the mastoid, it is commonly supposed that all serious danger 
of involvement of the intracranial contents is at an end, al- 
though the abscess may not be immediately evacuated by in- 
cision of the overlying soft parts. This is an error, particu- 
larly in the case of children. Here the sutural lines between 
the various portions of the temporal bone are not completely 
ossified, and when the external surface of the temporal bone 
is bathed in pus, infection, either through the sutural lines or 
through the substance of the squama itself, is by no means 
impossible. 

I have reported one case of this character in a child and 
one in an adult,* while several other instances may be found 
in otological literature. In children the presence of pus be- 
neath the integument in the post-aural region does not of ne- 
cessity indicate a perforation through the cortex. In these 
young subjects a collection of fluid within the tympanic vault 
frequently makes its way along the superior wall of the canal, 
gaining exit from the cavity through the Rivinian segment 
by dissecting the soft parts away from the bone in this loca- 
tion. In very young infants this is by no means uncommon, 
while in children over ten years of age it is occasionally met 
with. Perforation of the cortex on the anterior surface — that 
is, through the posterior wall of the bony meatus — may occa- 
sionally occur. Spontaneous evacuation here is probably due 
to the fact that in the particular case the external cortex is 
thicker, while along the posterior aspect of the canal the 
pneumatic cavities are well developed and thin-walled. Where 
sequestra are formed the process does not differ, except that 
in addition to the fluid collection we have a foreign body 
whose action is to aggravate the changes already described. 
The same remark applies to the development of a cholestea- 
tomatous mass within the mastoid cells. These epithelial col- 

* Archives of Otology, vol. xxi, p. 253. 
30 



442 INFLAMMATION OF THE MASTOID PROCESS. 

lections are rather prone to excite a hyperplastic inflamma- 
tion, terminating in sclerosis with obliteration of the trabecular 
between the cells. It is only when the mass attains consider- 
able size that acute inflammatory changes are set up, produc- 
ing a train of symptoms characteristic of an acute process in 
this region. 

The cholesteatomatous deposit may attain such a size as to 
cause absorption of the posterior wall of the canal, converting 
the mastoid, antrum, tympanum, and bony meatus into a single 
cavity. At the same time the cortex of the mastoid is often 
sclerosed. 

Symptomatology. — The prominent symptom met with is 
intense pain over the mastoid portion of the temporal bone. 
The pain is particularly severe at night, preventing sleep. It 
is of dull character, deep-seated and constant. Following a 
painful inflammation within the tympanum, a change in the 
character and location of the pain complained of by the pa- 
tient is a valuable symptom. The degree of constitutional 
disturbance presented is often entirely out of proportion to 
the local changes. The patient may be well nourished, the 
temperature normal, and the pulse but slightly accelerated, 
while at the same time extensive destruction is taking place. 
Where the disease complicates an acute process within the 
middle ear, or is primary in character, the temperature is 
usually elevated, varying from 99. 5 to 101.5 , but seldom 
higher than this. An extension of the pain to the temporal 
region is rarely complained of, its location being limited to the 
mastoid process. Where the cells are well developed at the 
apex, considerable difficulty may be experienced in moving the 
head from side to side. In children this symptom should al- 
ways be carefully investigated, although no pain may be com- 
plained of in the region of the ear. Tenderness upon deep 
pressure is probably the most characteristic sign of the in- 
volvement of the osseous structures. This varies considerably 
in location. It is usually most marked directly over the an- 
trum and close to the posterior margin of the canal. Occa- 
sionally the most tender point will be found at the tip of the 
apophysis. Where a previous aural discharge has been pres- 
ent, the access of the symptoms referable to the mastoid is 
frequently accompanied by a cessation of discharge from the 
canal or by a diminution in the amount. In young children 
who are unable to locate exactly the seat of pain, restlessness 



SYMPTOMATOLOGY— INTRACRANIAL INVOLVEMENT. 443 

at night should always excite suspicion if it follows the cessa- 
tion of a profuse aural discharge. Tumefaction behind the 
auricle is not common, except in early life. CEdema of the 
overlying soft parts is more characteristic of an inflammation 
within the canal than of involvement of the mastoid process. 
Fluctuation, it need hardly be said, indicates spontaneous 
evacuation of the purulent contents. 

If the intracranial structures are involved, the symptoms 
manifested depend upon the particular region attacked. If 
one of the large venous sinuses becomes the seat of an infec- 
tious thrombus, the temperature changes are the most charac- 
teristic evidence of the condition. They consist in the sud- 
den elevation of the temperature, the thermometer frequently 
registering 104 or 105 . This elevation persists but for a few 
hours, and is followed by a spontaneous fall to the normal 
standard or even lower than this. These intermittent eleva- 
tions may occur several times during the day, and may be of 
such short duration as to be unrecognized unless the tempera- 
ture is taken ^frequently. Following the access of the fever 
there is profuse perspiration, and as the condition advances, 
well-marked symptoms of general sepsis appear. The patient 
becomes very weak. The skin is of a dull, ashy hue, the 
pulse feeble, and the mental condition dull, all of which are 
indicative of profound systemic infection. If emboli are de- 
veloped, their lodgment in the various viscera is followed by 
characteristic symptoms. The most common site of lodgment 
is probably the lungs, causing a septic pneumonia. When the 
thrombus develops in the lateral sinus it frequently extends 
downward into the internal jugular vein, and its presence is 
revealed by deep tenderness along the course of this vessel, 
together with tumefaction along the anterior border of the 
sterno-mastoid muscle. Whenever temperature changes ex- 
cite suspicion of involvement of the sinus, the region of the 
external jugular vein should be examined frequently for con- 
firmatory signs. The sensorium is seldom disturbed, except 
just before death, where thrombosis alone is present. 

Where involvement of the intracranial structures results 
in diffuse meningitis, we have intense headache, photophobia, 
a high temperature which remains constant, nausea, and 
vomiting. Otitic meningitis usually involves the base of the 
brain rather than the convexity. Hence a slow pulse charac- 
teristic of traumatic meningeal inflammation is wanting, the 



444 INFLAMMATION OF THE MASTOID PROCESS. 

cardiac action being increased in rapidity. Paralysis of in- 
dividual muscles soon appears, the third and sixth nerves 
being- most frequently involved, causing either strabismus or 
paralysis of the ciliary muscle. Rigidity of the muscles of 
the neck occurs quite early, and is one of the most character- 
istic symptoms. 

Where the meningitis is localized, constituting an extra- 
dural abscess, the temperature is usually but moderately 
elevated, seldom exceeding ioo°. The characteristic sym- 
tom is localized headache, the painful region corresponding 
pretty closely to the area involved. Paralytic symptoms do 
not appear until late in the course of the disease. Rigidity 
of the muscles of the neck, vomiting and photophobia are 
also absent. 

The occurrence of an abscess within the cerebral sub- 
stance is a rare accompaniment of acute mastoid inflammation. 
It may be said it produces no symptoms which may be called 
characteristic until it has attained sufficient size to press upon 
some portion of the motor tract. Its presence should always 
be suspected when there is a persistent low temperature, to- 
gether with constant headache, increasing asthenia, and pro- 
gressive hebetude. So far from producing characteristic 
symptoms, it is rather the absence of any characteristic mani- 
festation, but the failure of the patient to improve, which 
should always excite suspicion of this condition. When in 
an acute mastoiditis the pain diminishes in severity and as- 
sumes the character of a general headache, while at the same 
time the patient becomes progressively dull and unobservant 
of his surroundings, the temperature remaining normal or but 
slightly elevated, invasion of the cerebral substance should 
be suspected. The occurrence of two or more of these intra- 
cranial conditions in association is what renders a diagnosis 
difficult. A brain abscess is not an uncommon complication 
of a thrombosis of one of the large venous channels. The 
thrombus causes the characteristic intermittent temperature 
and masks the purulent collection situated deeply within the 
cerebral tissue. It is also common to find considerable menin- 
gitis with either cerebral abscess or thrombosis of the lateral 
sinus. This local inflammation prevents the temperature from 
intermitting, as we should expect it to do if the sinus alone 
were involved, and the fever due to meningitis may render 
the fluctuations due to the entrance of infectious material 



DIAGNOSIS. 445 

into the circulation at frequent intervals entirely unrecog- 
nizable. 

Diagnosis. — It would seem that the recognition of the 
invasion of the osseous structures immediately surrounding 
the tympanum would be a matter of simplicity, and quite 
frequently no difficulty is experienced in making a diagnosis. 
On the other hand, we meet with cases in which even the 
most expert observer must be in doubt as to whether the 
pneumatic cells of the mastoid have become infected, or 
whether the severe constitutional symptoms are due simply 
to the conditions within the tympanum. There are two signs 
upon which the most dependence can be placed, and the pres- 
ence of both is a certain indication of mastoid involvement, 
while the presence of either one alone is certainly suspicious 
and often constitutes the sole sign upon which the necessity 
of operative treatment is based. 

These two signs are : 

i. Local tenderness upon deep pressure over the mastoid 
region. 

2. A depression or sagging of the supero-posterior wall 
of the canal close to the tympanic ring. 

In determining mastoid tenderness care must be taken to 
be sure that the pain experienced by the patient upon ma- 
nipulation is really mastoid tenderness, and does not depend 
upon an inflammation of the external canal. No error need 
occur if, when the examination is made, the examining finger 
is pressed backward and inward upon the mastoid just be- 
hind the insertion of the auricle, since this manipulation does 
not move the fibro-cartilaginous canal. On the other hand, 
if the finger of the operator causes even the slightest move- 
ment of the auricle or of the meatus, the presence of ah exter- 
nal otitis may lead to error. 

The tender point is usually situated over the antrum, and 
may be close to the margin of the bony meatus ; even here it 
is not necessary to cause the slightest motion of the soft parts 
if the thumb be placed upon the margin of the bony ring 
and pressure exerted backward and inward. The tenderness 
elicited is unmistakable, the patient not infrequently cringing 
at the moment when the parts are pressed upon. It is always 
wise to test the healthy mastoid in the same manner, since a 
certain number of individuals possess what may be called a 
physiological tenderness of the mastoid process. This is 



446 INFLAMMATION OF THE MASTOID PROCESS. 

probably due to a free distribution of the sensory nerves in 
this location, and is a rather characteristic symptom in nerv- 
ous and hysterical individuals. Occasionally the region of 
the antrum may not be tender, but pain is elicited when 
the tip of the mastoid is subjected to pressure. Here we 
must be cautious not to be misled by a tenderness over the 
Eustachian tube. This is elicited if the thumb is pressed 
upon the soft parts directly behind the ramus of the jaw, and 
is almost always found in cases of severe tympanic inflamma- 
tion. To avoid this error it is only necessary to direct the 
pressure backward upon the tip of the mastoid process, avoid- 
ing the soft parts immediately in front. Directly over the in- 
sertion of the sterno-mastoid muscle tenderness can almost 
always be elicited in healthy individuals even under normal 
conditions, and it is consequently of but little moment as a 
diagnostic sign. 

A localized tumefaction of the postero-superior canal wall 
is even more indicative of involvement of the mastoid than is 
tenderness behind the auricle. The examination of a large 
number of specimens will show that the pneumatic spaces are 
usually as richly distributed along the anterior face of the 
process — which constitutes the posterior wall of the canal — as 
beneath the external surface behind the auricle. The passage 
of communication between the vault of the tympanum and the 
mastoid antrum also lies immediately above and behind the 
inner extremity of the bony meatus, the postero-superior canal 
wall at this point forming the floor of the passage. This ex- 
plains why the sign is so important in establishing a diagnosis. 
In this condition we find the fundus of the canal much reduced 
in size, only a limited portion of the membrana tympani being 
visible, although the lumen of the meatus is normal in other 
situations. A primary external otitis is seldom met with in 
this locality, and I have never met with an instance in which, 
when this sign was present, operation upon the mastoid did 
not reveal the presence of pus. The tumor within the canal 
is extremely sensitive to pressure upon manipulation with the 
probe, and is dull and boggy to the touch. The presence of 
a large perforation in the membrana, through which secre- 
tion can be forced by auto-inflation, does not necessarily prove 
that the drainage of the mastoid process is competent. It 
will be remembered that the upper portion of the tympanic 
cavity is often completely shut off from the atrium under nor- 



DIAGNOSIS: SITE OF TUMOR. 447 

mal conditions, and when the parts adjacent are cedematous 
from inflammation complete obstruction is frequent. 

In addition to these two signs there is usually severe pain, 
especially at night ; or, if not pain, sleeplessness ; the last 
symptom is especially noticeable in chronic cases. To these 
patients the mastoid pain or headache has become a second 
nature, and a slight increase does not produce the same effect 
as the corresponding condition in a previously healthy individ- 
ual, but leads to loss of sleep. Body temperature has practical- 
ly no diagnostic value ; in acute cases we usually find an ele- 
vated temperature varying from ioo° to 102 or 103 . Where 
the middle ear has been the seat of a suppurative process for 
a long period, the mastoid subsequently becoming involved, 
it is not infrequent to find the temperature perfectly normal, 
although the temperature is taken so frequently as to pre- 
clude the possibility of any rise being overlooked. Local 
oedema behind the ear is more characteristic of a circum- 
scribed inflammation of the canal than of mastoid involve- 
ment. In young children, where the bony meatus is not de- 
veloped, tumefaction behind the ear is frequently found, and 
evacuation of the abscess may occur, although no perforation 
through the cortex is present. The fluid within the mastoid 
burrows along the postero-superior canal wall, and appears 
close behind the auricle quite early, owing to the ease with 
which it finds an exit through the Rivinian segment. In 
children, also, the cortex of the mastoid is exceedingly thin, 
and perforation may take place in twenty-four hours after 
the onset of an acute attack and produce the characteris- 
tic physical evidences. A condition which should never 
be forgotten is the occasional rupture of a mastoid abscess 
upon the internal surface through the digastric fossa. Here 
local tenderness over the antrum may be absent, the pain 
being referred to the lateral cervical region. In the early 
stages careful examination may reveal no difference between 
the corresponding regions of the sound and diseased side. 
At a later period a diffuse, brawny swelling is made out 
beneath the sterno-cleido-mastoid muscle, extending for a 
considerable distance both in front and behind it, the limits 
being poorly defined. Deep pressure over the tip of the 
mastoid elicits pain, which is frequently considered to be 
neuralgic in character, and depending upon the middle-ear 
lesion. Rupture at this point is rather characteristic of cases 



448 INFLAMMATION OF THE MASTOID PROCESS. 

which have existed for a long period, and where the mastoid 
process has undergone sclerotic changes with obliteration of 
the pneumatic spaces. It is all the more necessary to recog- 
nize the condition early, since from the consolidation of the 
parts invasion of the cranial cavity is prone to occur. Occa- 
sionally necrosis of the cervical vertebrae will lead to a mis- 
take in diagnosis, but the condition is so rare that it sel- 
dom leads to error. A marked diminution in the quantity 
of the discharge, with increased pain, should always make 
one suspicious of involvement of the mastoid. In cases 
of long standing the pain may not be localized, but dif- 
fuse headache is complained of. This, together with dimi- 
nution in the discharge, is sufficiently characteristic to de- 
mand operation if other measures fail to afford immediate 
relief. 

When the intracranial structures become involved the 
manifestations already given under symptomatology will usu- 
ally be sufficiently characteristic to lead the surgeon to recog- 
nize the condition, although, as stated before, the exact loca- 
tion of the lesion may be a matter of doubt. Here local 
tenderness is of considerable value in the absence of other lo- 
calizing data. Particularly in epidural abscess the most ten- 
der point is usually over the purulent focus. 

Prognosis. — An inflammation of the mastoid is always a 
grave condition. Following an acute middle-ear affection and 
promptly treated, the prognosis is usually favorable. In very 
young children, as a sequel of an acute infectious disease, es- 
pecially scarlet fever, the advance may be so rapid as to baffle 
all our efforts to check it. In adults the condition usually re- 
sponds promptly to treatment. Following a chronic purulent 
otitis the outlook is more grave ; this is particularly true of 
cases that have been neglected and which give the history of 
several previous attacks of pain referable to the mastoid re- 
gion, which have either subsided spontaneously or have dis- 
appeared under palliative measures. Cases where the perfora- 
tion through the drum membrane is located in the membrana 
flaccida present more extensive destruction of the osseous 
structures than those in which the loss of substance is in the 
membrana vibrans. The mastoid sclerosis which is frequently 
found in such cases renders intracranial involvement more 
common. A brain abscess which has developed and remained 
latent for many years may again become active by an acute 



PROGNOSIS— TREATMENT. 449 

exacerbation of the local process within the tympanum and 
mastoid. 

Diathetic conditions such as tuberculosis and specific dis- 
ease also render the prognosis more grave. As age advances, 
the powers of resistance are diminished, and any local disease 
becomes correspondingly more serious. Diabetes seems to 
cause the parts to break down with increased rapidity, and in 
such patients not only is the local process extensive, but inter- 
current complications of an infective nature are more com- 
mon. This should not, however, deter us from operating as 
early as the local condition demands it, since this measure af- 
fords us a means of cutting short the destructive process. 

With reference to the gravity of the mastoid operation it 
may be said that the procedure is in itself not dangerous. 
Very few cases are recorded in which the death of the patient 
can be traced to the operation, even although the cranial cav- 
ity may have been accidentally entered. An unfavorable ter- 
mination following an operation usually depends upon the 
extensive involvement found at the time, and is in no way 
traceable to the measure adopted for its relief. In sixty-one 
cases operated upon by the author, six terminated fatally. 
In one case facial erysipelas was the cause of death. The 
others were suffering from intercranial infection before the 
mastoid was operated upon. The effect upon a previous 
otorrhcea is almost invariably favorable if a thorough oper- 
ation is done, and it is safe to promise a cure not only of 
the immediate malady, but also of the affection which has 
existed so many years. 

Treatment. — When seen early, an attempt should be made 
to abort the attack ; the patient must be kept quiet, and usu- 
ally confined to his bed. The diet should consist of fluids 
only, and a brisk saline cathartic administered at once. 

If an otorrhcea is present, it must be ascertained whether 
drainage through the canal is free, and any bulging segment 
of the drum membrane should be thoroughly incised, the 
original opening being enlarged by means of a blunt knife. In 
executing this measure, it is imperative that the incision 
should be extensive, and so placed as to divide the numerous 
reduplications in the upper portion of the tympanic cavity. 
Even when there is no tumefaction of the anterior mastoid 
wall presenting in the canal, I am decidedly in favor of ex- 
tending the section through Shrapnell's membrane outward 



450 INFLAMMATION OF THE MASTOID PROCESS. 

along the superior wall of the canal for at least a quarter 
of an inch. After free drainage has been obtained, frequent 
irrigation with a mild antiseptic solution should be practiced 
both for cleansing purposes and to reduce the tumefaction of 
the parts. The application of cold to the mastoid is a valu- 
able measure in the early stages. It is most conveniently 
employed by means of the Leiter coil, care being taken that 
the appliance is molded so as to touch the mastoid at every 
point. It is not necessary to remove the apparatus when the 
ear is to be syringed. The coil should be kept in position 
continuously for at least twelve hours, and better for twenty- 
four. At the end of this time, if local tenderness persists, it 
is probable that an operation will be necessary. Under no 
condition should we employ cold for a longer period than 
forty-eight hours. The internal administration of narcotics 
,may be advisable during the first twenty-four hours, but after 
this time they should be withheld, as they only mask the 
symptoms. Local bloodletting was formerly much employed, 
and it can not be denied that it is efficient in some instances. 
The amount to be abstracted should be considerable, and in 
the case of an adult not less than four ounces should be re- 
moved. The objection to the procedure lies in the local ten- 
derness which follows, which may be frequently mistaken for 
that arising from the inflammatory proces. There is no objec- 
tion to its employment in connection with the use of the coil. 
As a diagnostic measure the application of cold is of value, 
since neuralgic pain is increased by the cold, while the suffer- 
ing caused by an inflammatory process is relieved by it. Tem- 
porary relief almost always follows, and herein lies* the danger 
of the measure being abused. Quite frequently spontaneous 
pain disappears completely after rest in bed and the employ- 
ment of cold locally for forty-eight hours. Upon examination, 
the condition of the parts may not be much changed, the canal 
presenting the same tumefied, swollen condition as before, 
while pressure elicits tenderness. The abatement in the 
symptoms will persist as long as the patient is kept quiet, but 
they return when he resumes his daily vocation. This ex- 
perience has so often fallen to my lot that I never continue 
the effort to abort the attack for more than forty-eight hours, 
feeling certain if marked improvement has not occurred in 
this time that operative treatment will be necessary sub- 
sequently. The value of Wilde's incision has been enor- 



TREATMENT. 45 r 

mously overestimated, and is only admissible in children. 
Here the cortex is so thin that the cells may be opened by 
firm pressure of the knife. In the adult, any symptom indica- 
tive of the advisability of this measure will become so much 
more marked within twenty-four hours that no doubt will re- 
main as to the advisability of opening the mastoid cells. It 
is certainly unwise to subject the patient to two operations 
when one will accomplish the desired result. The division 
of the soft parts within the meatus over the mastoid prac- 
tically meets all the indications of external incision, and in 
fact is much more efficacious, since depletion is more direct. 
The temperature scarcely calls for any special measures. If 
it is unusually high in the early stages, either phenacetine 
or acetanilide may be given in five-grain doses, repeated 
hourly until fifteen grains have been taken. These drugs 
relieve pain, and at the same time the discomfort which the 
elevation of body temperature causes. 

General headache, especially in young children, may fre- 
quently be relieved by the application of the ice cap, and 
from the ease with which the meninges may become involved 
secondarily, the measure is of value. Failing to secure satis- 
factory relief in forty-eight hours, operative measures are im- 
peratively demanded. Under no condition is it wise to delay 
the step longer than this time in chronic cases. Where the 
process complicates an acute middle-ear inflammation in an 
adult, or where it is primary, we would naturally hesitate 
about resorting to this measure at such an early period. 
Practically the question never arises, for in these acute cases 
enough relief is obtained from our milder measures to war- 
rant delay. As to the particular plan to be followed in the 
operation, the weight of evidence seems to be decidedly in 
the direction of freely opening all the mastoid cells, so that 
no infected area may escape observation. The old method of 
perforating the cortex by means of the drill scarcely merits 
discussion at the present day. Recovery is always tedious, 
and general sepsis a not infrequent complication, while the 
otorrhcea usually persists. 

When the entire cortex is removed and every vestige of 
softened bone taken away, while free drainage of the middle 
ear is established through the artificial opening, recovery is 
prompt and uneventful, while the aural discharge may cease 
at once, or, at most, by the time the external wound is healed. 



452 INFLAMMATION OF THE MASTOID PROCESS. 

Schwartze* was the first- to advocate a thorough expos- 
ure of the mastoid cells and the treatment of mastoid caries 
upon the principles of general surgery. In this country 
Gruening has advocated the removal of the entire cortex in 
all cases and has formulated the operation more exactly than 
any other writer. 

The operative technique is described in the section de- 
voted to operative surgery. 

* Arch, fur Ohrenheilk. , vol. vii, p. 157. 



CHAPTER XXVI. 

intracranial complications of tympanic inflammation. 

Otitic Meningitis. 

The meninges may be invaded in aural suppuration either 
from the middle ear itself or through the complicating in- 
volvement of the mastoid process. This invasion may occur 
by extension from caries of the osseous walls and evacuation 
of pus into the cranium, or by infection through the numer- 
ous vessels which perforate the internal table of the skull. 
In children it is not an uncommon complication of a suppura- 
tive inflammation of the middle ear. The process may affect 
the entire surface or may be localized, the favorite seat being 
the basilar meninges. 

Symptomatology. — This affection is usually accompanied 
by high temperature, which remains constant, exhibiting but 
few fluctuations, and varying from ioi° to 105 . There is 
severe headache, photophobia, vomiting, and localized or 
general convulsions. In children general convulsive symp- 
toms are particularly common, owing to the high tempera- 
ture. In adults a basilar meningitis does not produce this 
symptom, but affects groups of muscles supplied by the par- 
ticular nerves involved at their points of exit from the cranial 
cavity. These muscular contractions are succeeded by paral- 
ysis as the disease advances. When the basilar meninges 
are affected, the respiratory movements are changed in char- 
acter quite early, and soon assume the peculiar variety known 
as " Cheyne-Stokes respiration," in which there are several 
short efforts at inspiration, followed by a period of com- 
plete cessation of the respiratory movements, the lungs be- 
ing finally emptied by a long sighing expiratory effort. 
Delirium occurs early in young subjects, but in adult life the 
sensorium is often not involved until quite late, and delirium 
may not occur at all, the patient slowly passing into a condi- 
tion of coma, in which state he dies. The paralyses most fre- 

(453) 



454 



COMPLICATIONS OF TYMPANIC INFLAMMATION. 



quently met with are those caused by the involvement of the 
third, fourth, and sixth nerves. An implication of the third 
nerve causes at first contraction of the pupil, and later dilata- 
tion. One of the earliest symptoms of paralysis is failure of 
the pupil to respond to light, it remaining dilated when ex- 
posed to a brilliant source of illumination. The involvement 
of any of the nerves above mentioned will produce stra- 
bismus. 

Diagnosis. — The recognition of the affection depends upon 
the preceding history, associated with constant high tempera- 
ture, vomiting, and headache. This group of symptoms can 
be characteristic of no other disease complicating an otitis in 
adult life. The exclusion of any acute intercurrent affection 
naturally depends upon the absence of symptoms character- 
istic of such a disease. In children the diagnosis is much more 
difficult, since any acute infectious disease or a disturbance 
of the gastro-intestinal canal will give rise to exactly the symp- 
toms above mentioned. 

The cessation of the discharge from the ear coincident 
with the above manifestations should always render us sus- 
picious of intracranial involvement, while the appearance of 
tonic spasm of individual muscles, such as those at the nape 
of the neck, is a valuable confirmatory sign. Photophobia, 
involvement of the ocular muscles, the interference with the 
respiratory movements, and subsequently coma, render the 
diagnosis simple in most cases. 

Prognosis. — Meningeal infection is usually fatal, and yet 
the results obtained by Macewen,* who reports six recoveries 
after operation, prove that death does not always follow. 

Treatment. — The application of ice to the head is agree- 
able, and may retard to some extent the progress of the in- 
flammation. The administration of large doses of bromide 
of sodium or potassium is also indicated, as it lessens the 
irritability of the nerve centres. Opiates should be avoided, 
but may be necessary to relieve the intense pain. Free pur- 
gation by means of salines should be resorted to at once. The 
administration of iodide of potassium internally is permissible, 
on the assumption of a possible specific taint, either hereditary 
or acquired. Surgical measures are to be employed, but to 
be of service must be resorted to early. As the disease will 

* Diseases of the Brain and Spinal Cord, American edition, 1893, p. 329. 



SINUS THROMBOSIS. 455 

certainly prove fatal if it is not checked by operation, the 
surgeon should not hesitate to interfere even in cases which 
are apparently hopeless if the diagnosis is unquestionable. 

Sinus Thrombosis. 

The occlusion of one of the large venous channels within 
the cranium by an infectious thrombus is always to be re- 
membered as one of the possible complications of acute or 
chronic suppuration within the tympanum. 

The free communication through the mastoid veins be- 
tween the lateral sinus and the pneumatic spaces immediately 
covering it, renders a suppuration within this cavity particu- 
larly prone to deposit septic material within the lateral sinus. 
Not only may a suppurative process within the mastoid be 
complicated by this lesion, but a middle-ear suppuration 
alone, without involvement of the mastoid structures, may 
cause the condition as well. Here the channel of infection 
may be the superior petrosal sinus or some of the smaller 
venous tributaries. When such a deposit takes place, the 
first step of the process is the occlusion of the sinus by a firm 
fibrinous clot. The development of pyogenic bacteria within 
this mass leads to general septic infection, by the entrance of 
bacteria into the general circulation. The thrombus may re- 
main localized within the sinus itself, affecting but a small 
area, or it may extend to the internal jugular vein. General 
infection may take place through the lateral sinus from peri- 
phlebitis, the outer cranial wall, which is deeply grooved for 
the passage of the vessel, becoming necrotic or carious, and 
exciting an inflammation of the outer wall of the lateral sinus, 
lying in immediate contact with it. This is communicated 
to the interior of the vessel, causing its occlusion in the man- 
ner above described. Such a periphlebitis may lead to erosion 
of the venous trunk before its lumen is occluded by a firm 
clot, and cause a profuse haemorrhage. 

Provided life is prolonged for a sufficient period to permit 
of general infection, we find secondary purulent deposits in 
various organs of the body. The lungs seem to be the favor- 
ite site of infection, septic pneumonia being the most com- 
mon complication. 

Secondary brain abscess is also met with, and secondary 
thrombosis of some of the other venous sinuses within the 
cranium as well. It is interesting to note that the primary 



456 COMPLICATIONS OF TYMPANIC INFLAMMATION. 

aural affection and the primary sinus thrombosis may cause 
secondary thromboses and brain abscesses upon the opposite 
side. For this reason much uncertainty exists as to the ulti- 
mate outcome of any operative procedure directed toward 
the primary seat of affection. 

Symptomatology. — The symptoms to which this affection 
gives rise are insidious in their development, and may escape 
notice for a considerable period. The symptom character- 
istic of the involvement of one of the large venous channels 
is a sudden rise in temperature followed by a spontaneous 
fall to normal or nearly normal. This may be the only symp- 
tom, and, unless the temperature is taken at frequent intervals, 
may entirely escape observation. The sudden rise in tem- 
perature — which is usually excessive, and may reach 104 or 
106 — is due to the passage of septic material into the gen- 
eral circulation at successive intervals, owing to the breaking 
dowm of the clot within the sinus. After this condition has 
continued for some time, symptoms of general sepsis develop, 
such as asthenia, emaciation, and an ashy hue of the skin. 
The rise in temperature is usually followed by profuse per- 
spiration. In the late stages constitutional depression accom- 
panies this, but when the patient is in fairly vigorous health, as 
at the onset of the disease, this depression may be so slight as 
to escape observation. A severe rigor is not an unusual symp- 
tom, and is met with in many cases, but is quite frequently 
wanting. Where it occurs it is of great diagnostic impor- 
tance, but its absence renders the exclusion of sinus thrombo- 
sis by no means certain. Symptoms referable to the cranial 
contents — such as headache, local or general convulsions, 
paralysis, mental dullness, or delirium — are absent in uncom- 
plicated cases. Where met with in connection with evidences 
of sinus thrombosis, we should always suspect the involve- 
ment of either the cerebral substance itself or of secondary 
meningitis affecting a considerable portion of the brain cover- 
ings. When there is a secondary process in some remote organ 
from the lodgment of infectious emboli, we have, in addition 
to the rise in temperature, symptoms peculiar to the organ 
involved. As stated above, these deposits occur most fre- 
quently in the lungs, and a septic pneumonia is the most com- 
mon complication. This is of the lobular type, isolated areas 
of the pulmonary tissue becoming consolidated, and either 
resolving subsequently or breaking down with the formation 



SINUS THROMBOSIS— DIAGNOSIS. 



457 



of a pulmonary abscess. The liver and spleen may also be 
the seat of these deposits, but the symptoms presented are 
so vague as to escape recognition, and the condition is dis- 
covered at the necropsy only. 

Diagnosis. — The recognition of involvement of the sinus 
alone would be an exceedingly simple matter were not com- 
plicating lesions so frequently present. The early recognition 
of the condition is of the greatest importance, and the one 
means which enables us to effect this end is to insist that the 
temperature shall be taken at frequent intervals — say every two 
hours during the day and every four hours during the night. 
Where the temperature is taken but twice daily, the affection 
may escape recognition for a long time, during which period 
secondary deposits may have occurred either in the viscera 
or in the brain itself, converting a comparatively simple con- 
dition into one of extreme gravity. 

The second symptom of diagnostic importance is the de- 
velopment of an asthenic condition without sufficient local 
disturbance, either in the middle ear or mastoid, to fully ac- 
count for its occurrence. By exclusion this can only come 
from general sepsis, and its sudden development is indicative 
of the conveyance of the septic material into the blood cur- 
rent through a channel of considerable size. The occurrence 
of rigors and profuse perspiration are of great diagnostic 
value. The examination of the ear or of the mastoid wound, 
if an operation has been performed, furnishes practically no 
information of value. 

Prognosis. — A certain proportion of these cases of pri- 
mary thrombosis recover spontaneously, although it is im- 
possible to say how many die subsequently from the develop- 
ment of a cerebral abscess. Pulmonary involvement is not 
of necessity fatal, the local process gradually disappearing if 
the powers of resistance of the patient are sufficient. Death 
usually occurs either from profound systemic infection, from 
the development of diffuse meningitis, from the formation of 
a cerebral abscess, or from extensive pulmonary involvement. 

Treatment. — The operative treatment proper in these 

cases will be discussed in the section devoted to surgery. 

This, I believe, should always be adopted when the diagnosis 

is certain. The only therapeutic measures to be employed 

are those which will most successfully combat the asthenic 

condition. The free administration of stimulants is indicated, 
31 



458 COMPLICATIONS OF TYMPANIC INFLAMMATION. 

alcohol probably being the best, as it acts both as a food 
and as a stimulant. When superficial abscesses develop, they 
are to be opened according to the general rules of surgical 
practice. The exhibition of large doses of quinine seems to 
be of value in diminishing the febrile movement, thus curtail- 
ing the excessive tissue waste. Particular attention should 
be paid to the nutrition of the patient. The systematic ad- 
ministration of milk, eggs, and other highly nutritious and 
easily digested foods, should be placed in the hands of an ex- 
perienced nurse, to aid the patient to combat successfully the 
infectious process. Where the stomach becomes intolerant, 
the food should be artificially digested before it is adminis- 
tered. Rectal alimentation may be necessary in some cases. 

Extradural Abscess. 

This condition is essentially one of localized purulent 
meningitis, in which the vis medicatrix naturce has limited the 
suppurative process to a smaller area of meningeal surface. 
In this condition we find the meninges adherent to the inter- 
nal table of the skull, completely walling in the purulent col- 
lection and preventing the development of diffuse inflamma- 
tion. Most commonly an abscess between the dura mater 
and the internal table of the skull is a complication of a 
chronic suppurative process within the middle ear or mas- 
toid. The thin wall separating the lining membrane of the 
middle ear and mastoid process from the meninges becomes 
necrotic. During the period in which this process is taking 
place a localized meningitis of a low grade is developed 
about the affected area, so that when the necrotic portion 
separates, the corresponding dural area is completely shut off 
from the general cranial cavity. This evidently can not occur 
when the progress of the disease is rapid, the development of 
organized tissue taking place only after a considerable period 
of time. A similar localized meningitis may occur from the 
lodgment of an embolus or from thrombosis of a venous tribu- 
tary, or often of one of the larger sinuses. For some reason 
the thrombus does not break down rapidly, but causes a 
subacute inflammation of the tissues inclosing it, so that when 
ulceration takes place there is no communication with the 
general cranial cavity. 

Symptomatology. — This condition produces few symp- 
toms characteristic of its presence. The two most important 



EXTRADURAL ABSCESS. 459 

sisfns are severe and continuous headache, localized over the 
affected area, a moderately elevated temperature, seldom 
above 101.5 or 102 , which undergoes slight fluctuations, but 
seldom reaches the normal standard. Localizing symptoms 
are rare, no portion of the motor tract being pressed upon. 

When situated in the cerebellar fossa, vertigo and vomiting 
may occur. Mental dullness is met with in the last stages 
without reference to the location of the abscess, and is prob- 
ably dependent upon the increase in intracranial pressure 
from effusion into the ventricles. The chief diagnostic symp- 
toms, however, are the temperature and the headache, which 
continue in spite of a free opening in the mastoid process. 
The temperature is not sufficiently elevated to indicate throm- 
bosis or meningitis, this latter being also excluded on account 
of the mild character of the symptoms, while the absence of 
any localizing manifestations and the elevation of temperature 
serve to distinguish it from an abscess in the cerebral sub- 
stance. The headache is apt to be localized, and over the 
painful areas the parts are often exquisitely sensitive to pres- 
sure. This sharply localized tenderness is of importance in 
determining the location of the abscess. 

Prognosis. — A collection of pus in this situation may re- 
main latent for a long period. Any acute process involving 
the middle ear or mastoid may excite it to renewed activity, 
causing an acute diffuse meningitis or rupture of the abscess, 
either with evacuation into the cranial cavity or cerebral sub- 
stance. Death may be caused by the increased pressure if 
the rupture is intracranial, or external rupture occasionally 
takes place, with abatement of the symptoms. When the 
abscess is recognized and evacuated, recovery is the rule. 
Spontaneous evacuation through the outer wall of the cra- 
nium, with subsequent favorable progress, has occurred in 
two cases observed by Knapp. The abscesses opened near 
the occipital protuberance in both cases. 

Treatment. — Internal medication should be limited to the 
administration of supporting and stimulating agents. The 
only curative measure is the evacuation of the abscess, the 
technique of which procedure will be described later. 

Cerebral Abscess. 

A localized purulent focus within the brain tissue may be 
either acute or chronic in its development. The acute cases 



460 COMPLICATIONS OF TYMPANIC INFLAMMATION. 

are exceedingly rare, while it is probable that the most com- 
mon cause of chronic cerebral abscess is a purulent otitis. 
These abscesses may be single or multiple ; they may involve 
the cortex or the deeper regions of the brain, and may be 
limited to one side, or may be met with in both cerebral 
hemispheres. They may follow either a simple inflammation 
within the tympanum, with the formation of pus, or a similar 
condition within the mastoid, an infectious thrombosis, or an 
epidural purulent collection. The locality most frequently 
affected is the temporo-sphenoidal lobe, and the next in fre- 
quency is the cerebellum. Occasionally a similar process is 
found in the medulla. As a rule, they are situated rather 
deeply in the cerebral substance, and if left to themselves 
may rupture into the lateral ventricles. Discharge of the 
contents through the meninges occasionally occurs where the 
accumulation is superficial, and in rare instances the pus finds 
its way through a perforation in the tympanic roof, and ap- 
pears externally as a discharge from the meatus.* An abscess 
may remain latent for a period of many years, being excited 
to renewed activity by the occurrence of an acute inflamma- 
tion of the region primarily involved. 

Examination of many of these abscesses shows that the 
fluid is sterile, artificial cultures being entirely inert. 

Symptomatology. — If located so that pressure is exerted 
upon the motor tract or upon the motor area in the cortex, 
localizing symptoms occur. These are at first of a convulsive 
character if the process is acute, but when chronic the in- 
crease in pressure develops so gradually that the various 
areas are destroyed completely without any previous stage 
of excitation. Hence the paralytic stage is not preceded by 
one characterized by convulsive seizures. 

The favorite site for the development of this abscess is in 
the temporo-sphenoidal lobe, and hence characteristic local- 
izing symptoms are only produced when the abscess has at- 
tained considerable size, in which case it involves the speech 
area, and produces either sensory or motor aphasia. Located 
within the cerebellum, unsteadiness in gait and vomiting con- 
stitute the characteristic symptoms, although these do not 
appear unless the middle lobe of the cerebellum is pressed 
upon. The asthenic symptoms are more indicative of the 
affection than are any special manifestations. From a rapid 
increase in the size of the abscess, local or general convulsions 



CEREBRAL ABSCESS. 461 

may occur ; the pulse may be accelerated in acute cases, the 
relation between the pulse and the temperature being the re- 
verse of that characteristic of meningitis. In the chronic cases 
development is so insidious that the first symptom noticed is a 
condition of marked physical impairment. The mental status 
furnishes valuable information as well, the patient being irri- 
table at times, while at other times he is either inattentive 
or even somnolent. This condition of hebetude gradually 
deepens to one of coma. The temperature is seldom elevated 
above 99 ; the pulse is usually normal, occasionally intermit- 
tent. Headache of a dull, diffuse character is complained of 
in cases of long standing. Sometimes sleeplessness is the 
only symptom for which the patient seeks advice. 

The termination of the case is usually sudden, death 
taking place from rupture into the ventricles or from com- 
pression or destruction of the vital centres. 

Diagnosis.— In discussing mastoid inflammation, it was 
stated that the recognition of a cerebral abscess depended 
principally upon the gradual and steady impairment of the 
general health without any sufficient local cause, and, in the 
absence of symptoms, pointing to either meningitis, extra- 
dural abscess, or sinus thrombosis. 

Bergmann,* in his monograph upon the surgical treatment 
of intracranial disease, asserts that the history of otorrhcea, 
past or present, together with persistent sleeplessness and a 
temperature remaining steadily at about 99 , are sufficient 
indications for opening the cranial cavity for the purpose of 
exploration. The experience of this surgeon would certainly 
lend great weight to his statement ; but in the cases which 
come under the observation of the otologist we may usually 
wait until some localizing symptoms develop or until the con- 
dition of hebetude is well pronounced before we interfere. 
The advantage of delay lies in the fact that more precise in- 
dications as to the particular location of the abscess may 
appear in the late stages, while the danger to the patient is 
not materially increased. 

Complicating lesions may render the diagnosis difficult, 
and it is well to bear in mind that an otitis upon one side may 
produce an abscess of the opposite cerebral hemisphere, a 
fact which still further complicates our diagnosis. 

* Hirnkrankheiten. 



462 COMPLICATIONS OF TYMPANIC INFLAMMATION. 

An examination of the field of vision may yield valuable 
information in locating- the abscess. The ophthalmoscope 
may reveal the presence of choked disc, but this appearance 
is indicative of an intracranial lesion simply, and is not char- 
acteristic of abscess alone. 

Prognosis. — Unless surgical aid is invoked an abscess with- 
in the brain substance must cause death. It is proper, there- 
fore, to resort to surgical measures as soon as the diagnosis is 
made. In some instances it is wise to wait for the develop- 
ment of symptoms which will indicate the situation of the pu- 
rulent collection. This interval will depend much upon the 
general condition of the patient, and it is to be remembered 
that the operation is not to be delayed until the patient is too 
much exhausted to react from the operation. Of nineteen cases 
operated upon by Macewen,* eighteen recovered, while Kor- 
ner f has collated fifty-five cases operated upon, twenty-nine 
of which recovered. 

Treatment. — Nothing but operative interference is of the 
slightest avail in these cases. Until the surgeon is ready to 
operate, the treatment should be directed to improving the 
nutrition of the patient, so that he may be able to react from 
the operation. The technique of the operation will be con- 
sidered in a separate section. 

* Pyogenic Infective Diseases of the Brain and Spinal Cord, Am. Ed., New York, 

1893, P- 333- 

f Die otitischen Erkrank. des Hirns, etc., 1894, p. 145. 



SECTION III. 

SURGERY OF THE CONDUCTING APPARATUS. 



SURGERY OF 
THE CONDUCTING APPARATUS. 



Under this section we shall consider those procedures de- 
manded by various pathological conditions affecting this por- 
tion of the body. While the term embraces all operations 
upon the auricle, canal, tympanum, mastoid, and adjacent re- 
gions, it is evident that many of these belong more to the do- 
main of general than of special surgery. In this section we 
shall confine ourselves to those operations which are not con- 
sidered in detail in works on general surgery and which are 
of interest to those engaged in special work. 

For this reason operations for the removal of neoplasms of 
the auricle or for the correction of deformities of the external 
ear will not be described. On the other hand, the frequent 
occurrence of intracranial complications as the result of aural 
suppuration renders the consideration of the proper treat- 
ment of such affections imperative. 



CHAPTER XXVII. 

middle-ear operations. 

Preparations Preliminary to Operations upon the 
Tympanic Cavity. 

Instruments. — Every operator will from habit develop a 
preference for some particular form of instrument which in 
his hands will be more valuable than one of another pattern. 
Emphasis should be laid upon the fact that in this branch' of 
surgery, as in all its branches, the object to be attained should 
be kept in mind rather than the particular appliance with 
which it is to be effected. In a general way the operator 

(465) 



4 66 



MIDDLE-EAR OPERATIONS. 



should have at hand delicate, sharp and probe-pointed knives, 
of both the curved and the straight variety ; a number of an- 
gular knives, the blade in each knife being bent close to the 
point, either to an obtuse or right angle, according to the par- 
ticular use for which it is intended ; several blunt and sharp 
hooks, varying in size and curve ; curettes ; sharp spoons, both 
straight and angular ; delicate forceps for removing detached 
portions of tissue, and an ecraseur for the same purpose. In 



n 



i 



f ^ 



IT 



TT1 






^ 



(?***=% 



[' 



h 



u> 



a be d e f g h i J k 

Fig. 123. — Instruments for middle-ear operations. 

addition to these, the ordinary speculum used in examination 
will be necessary, together with a large number of cotton hold- 
ers for cleansing the parts during the course of the operation, 
and probes, both stiff and flexible, for tactile exploration. It 
has been a matter of much discussion as to the advisability of 
using a straight knife or one in which the handle makes an ob- 
tuse angle with the shaft in operations of this character. The 
question should be decided by individual experiment. For 



PREPARATION OF THE EAR. 467 

the past two years I have employed with great success a series 
of instruments the blades of which are forged from small steel 
wire of the correct size (Fig. 123). The shaft of each instru- 
ment is provided with a screw thread which enables it to be 
fastened firmly into a small handle made of octagonal brass 
rod. The shank of the knife is left malleable, which permits 
of its being bent at an angle with the handle, or being used as 
a straight instrument, according to circumstances. These 
instruments are comparatively cheap, and this is a matter of 
considerable consequence, as the instruments become useless 
after a few operations. It is important that all knives should 
possess sufficient thickness at the back to permit the blades 
to be honed to a keen edge. No cutting instrument which is 
thin and spatula-like can be brought to a fine edge, no matter 
how much care is exercised. Too much stress can not be laid 
upon the necessity of having all cutting instruments as sharp 
as care and art can make them. It may seem superfluous to 
lay much stress upon this point, but it is so commonly neg- 
lected in aural surgery that I feel warranted in emphasizing 
it here. 

Concerning the preparation of the instruments for opera- 
tion, immersion in a boiling soda solution of the strength of 
one per cent has in all cases proved satisfactory. The larger 
instruments, such as forceps, probes, specula, etc., may be al- 
lowed to remain in the boiling solution for from three to five 
minutes. Delicate knives, however, should be simply im- 
mersed for a moment and then withdrawn. 

Preparation of the Field of Operation. — Where there has 
been no discharge from the external auditory meatus it usu- 
ally suffices to cleanse thoroughly the ear at the time of the 
operation by means of a solution of bichloride of mercury of 
the strength of 1 to 3,000 in equal parts of alcohol and water, 
the lotion being applied by means of a cotton-tipped probe. 
The walls of the canal should be thoroughly scrubbed so as 
to remove not only any superficial deposit which may be pres- 
ent, but also any desquamated epithelium which may adhere 
closely. It is better, however, to precede this cleansing by 
having the ear syringed once daily upon the two days preced- 
ing the operation with an aqueous solution of the bichloride 
of mercury of the strength of 1 to 5,000, the canal being oc- 
cluded by a pledget of sterilized cotton immediately after the 
irrigation and the pledget allowed to remain in situ until the 



468 MIDDLE-EAR OPERATIONS. 

next cleansing. It is a fact not ordinarily recognized that 
low vegetable organisms, such as various forms of aspergillus, 
are encountered quite frequently in the external auditory 
meatus, and in no small degree tend to excite inflammatory 
action after operative procedures ; and it is for the purpose 
of thoroughly eradicating these growths from the field of 
operation that the above measures are advised, even in cases 
where the canal seems perfectly clean. Where there has been 
an otorrhcea of long standing it is still more necessary to 
cleanse the parts thoroughly by irrigation with antiseptic lo- 
tions before resorting to any operation. Thorough syringing, 
either once or several times daily, according to the amount of 
discharge, is imperative for at least five days before any op- 
erative procedures are attempted. The particular antiseptic 
chosen is a matter of little importance ; the bichloride-of-mer- 
cury solution of the strength of i to 5,000, or a dilute solution 
of peroxide of hydrogen, or of carbolic acid 1 to 50, or a satu- 
rated solution of boric acid, are all fairly efficient. Either a 
few hours before the operation or immediately preceding it 
the field should be cleansed with the alcoholic solution in the 
manner mentioned before. 

Where proper attention has not been paid to cleanliness, 
we frequently find in old cases of otorrhcea that the tympa- 
num is filled with exuberant granulations due to the effect of 
heat and moisture, as well as to the presence of necrosed bone. 
Cleansing will do much to reduce these efflorescent masses, 
but it may be necessary to curette thoroughly the entire cav- 
ity before any further operative measure is employed, in order 
that the extreme vascularity of the parts may not interfere 
with a delicate operation in such a limited field. Where evul- 
sion is not indicated the actual or chemical cautery may re- 
duce the granulations sufficiently. 

Anaesthesia. — Where the membrana tympani is present it 
is usually possible to perform the various operations upon the 
middle ear under local anaesthesia, provided the patient pos- 
sesses a fair amount of self-control. In operations having for 
their object an improvement of the hearing it is particu- 
larly advantageous that the patient shall retain consciousness 
throughout, in order that the results of the various steps may 
be closely noted. The primary incision through the mem- 
brane is the only step attended with pain, and this is insignifi- 
cant where the knife is in a proper condition. Absolute anass- 



CLASSIFICATION OF OPERATIONS. 



469 



thesia is obtained subsequently by touching the edges of the 
incision with a cotton-tipped probe moistened in a ten-per-cent 
solution of cocaine, the probe being subsequently introduced 
into the tympanic cavity to anaesthetize its lining membrane. 
Where the procedure has for its object the removal of carious 
or necrotic bone and involves the necessity of curetting the 
cavity thoroughly, general anaesthesia should always be em- 
ployed. For the division of adhesions in residual purulent 
cases even local anaesthesia may not be necessary, as the parts 
are but slightly sensitive. 

The Position of the Patient. — Since we are accustomed 
to inspect the ear with the patient either in an erect or semi- 
recumbent posture, it is some- 
what inconvenient to operate 
with the subject in the hori- 
zontal position. In addition 
to the distortion which the 
parts suffer, the posture of the 
surgeon must be cramped and 
uncomfortable. These condi- 
tions are not favorable to deli- 
cate manipulations. If a gen- 
eral anaesthetic is necessary 

the upright position is not FlG - 124.— Author's head and shoulder 

available, but here it is always 

advisable to operate with the shoulders elevated so that the 
head can easily be turned in any direction. The rest shown 
in Fig. 124 will be found convenient in securing this end if a 
suitable operating chair or table is not at hand. 

Classification of Operations. 

The various intratympanic operations may be classified as 
follows : 

I. Operations involving the Membrana Tympani alone, com- 
prising, (a) Perforation of the membrane (myringotomy), (b) 
Removal or destruction of a segment of the membrane to 
establish a permanent opening (partial myringectomy). (c) 
Single or multiple incision of the membrana tympani to cor- 
rect anomalies of tension. (We include here section of the 
posterior fold, or plicotomy.) 

II. Operations involving the Intratympanic Soft Parts. — {a) 
Tenotomy of the tensor tympani muscle, (b) Section of 




470 



MIDDLE-EAR OPERATIONS. 



the anterior ligament of the malleus, (c) Section of adhesions 
resulting from suppurative or nonsuppurative inflammation. 

III. Operations involving the Ossicular Chain. — (a) Excision 
of a portion of the malleus. (J?) Disarticulation at the incudo- 
stapedial joint, or division of the long arm of the incus, with 
mobilization of the stapes, (c) Plastic operations for uniting 
either the stapes or the incus to the membrana tympani 
directly, (d) Excision of individual ossicles, or of the entire 
ossicular chain. 

I. Operations involving the Membrana Tympani alone. 

(a) Myringotomy. — A simple incision through the drum 
membrane may be performed either to evacuate fluid, to 
deplete the parts, or for the purpose of exploration. Former- 
ly the drum membrane was considered 
so important a structure that interfer- 
ence with it was seldom deemed justi- 
fiable. Too much can not be said for 
the purpose of correcting this error. 
Granting that the instruments, the field 
of operation, and the operator are asep- 
tic, an extensive incision through the 
structure, even in a state of health, will be 
followed by no untoward consequences. 
The linear wound will heal completely 
within twenty-four hours and the func- 
tion of the organ will in no way be in- 
terfered with. For whatever purpose 
the procedure is employed, it should al- 
ways be remembered that the incision 
should be free rather than limited in ex- 
tent. Formerly, for the evacuation of 
fluid within the tympanum it was the 
custom to " puncture " the drum mem- 
brane with a small lance-shaped knife 
(Fig. 125). The failure to secure speedy 
convalescence was then attributed to the operation. At the 
present day, when we wish to evacuate fluid from the tym- 
panum, the parts are freely incised and the cavity emptied, 
and at the same time the vascular turgescence is relieved, 
so that the cut edges approximate closely and unite at the 
end of a few hoars. 




FlG. 125. — Myringotome. 



MYRINGOTOMY. 



47 



Operation. — The field of operation and the instruments 
being thoroughly aseptic, the surgeon exposes the fundus of 
the canal by the insertion of a speculum of the proper size. 
The site of election for perforating the drum membrane varies 
according to the manifestations in each particular case. If 
fluid is to be evacuated our incision should commence at the 
most prominent point and should extend either upward or 
downward through the bulging portion. Section is most 
effective by using the sharp knife shown in Fig. 123, e. If the 
bulging involves chiefly the upper part of the drum mem- 
brane the knife should be carried into the canal with the cut- 
ting edge upward. Its point is entered at the apex of the 
tumefaction and carried rapidly through the drum until it im- 
pinges upon the internal tympanic wall, after which it is made 
to cut upward toward the periphery as far as may seem neces- 
sary (Fig. 97). As the most prominent region is almost in- 
variably in the posterior quadrant, and usually in the postero- 
superior, care must be taken to avoid striking the long por- 
tion of the incus with the point of the knife. When the pri- 
mary incision is made the malleus shaft can usually be suffi- 
ciently well made out to be avoided ; but if the knife impinges 
upon this the operator will have failed to secure a proper 
opening, the resistance being firm and the knife seldom glid- 
ing off so as to pass through the membrane and evacuate the 
contents of the cavity. To avoid injuring the incus and stapes 
it is necessary that the operator should hold the instrument 
delicately between the thumb and finger in making the up- 
ward stroke, when contact with these structures will be im- 
mediately recognized, and the blade may be slightly turned 
so as to avoid them. Where the most prominent area corre- 
sponds to the low r er half of the tympanic cavity incision in the 
opposite direction is usually more convenient. In this case the 
knife is introduced in the canal with the cutting edge down- 
ward. Here no important structures can be encountered and 
the procedure is relatively simple. It is usually wise to make 
this incision somewhat curvilinear, following the peripheral 
attachment of the membrane, the incision passing close to the 
cartilaginous ring. Approximation is more perfect when the 
wound is located here and cicatrization correspondingly more 
rapid. In all cases attended with congestion or an inflamma- 
tory process the inner tympanic wall should be incised at the 
same time to secure local depletion. Regarding the absolute 



472 



MIDDLE-EAR OPERATIONS. 



extent of the incision, it is seldom wise that this should be 
shorter than one fourth of the long diameter of the membrane 
if lying in a vertical direction, or less than one eighth of the 
periphery if located near this. 

It is well to remember that the plane of the membrana 
tympani is obliquely placed to both the horizontal and vertical 
transverse planes of the body. An instrument introduced 
into the meatus and carried horizontally inward will frequent- 
ly not pass through the drum membrane, but will be de- 
flected from its surface and inflict but a superficial wound. 
This is particularly true when the bulging involves the supe- 
rior segment, and in children. In order to enter the tym- 
panic cavity the knife must be passed not only inward, but 
inward and upward, and even after the point has, passed 
through the membrane the handle should be strongly de- 
pressed, so as to carry the blade well up into the cavity. In 
an infant the plane of the membrane is nearly horizontal, and 
unless particular attention is given to this fact the operation 
will be inefficiently performed. It is well in operating upon 
a young child, and even upon an adult where the canal is nar- 
row, to employ a curved knife (Fig. 87) rather than a straight 

one, as an extensive incision is 
more easily made if this is done. 
Where myringotomy is per- 
formed for depletion alone in 
those cases where the acute in- 
flammatory process has begun 
in the vault of the tympanum, 
the atrium remaining free, our 
success in aborting the attack 
will depend largely upon the 
thoroughness with which we 
divide the connective -tissue 
structures lying in the tym- 

Fig. i26.-Incision of Shrapnell's mem- P anic vault In such a case the 
brane in the early stages of acute knife should be introduced with 
purulent otitis. (The continuation . ,111. . ,, , 

of the incision upon the superior the blade lying in the horiZOn- 
wall of the canal is indicated by the ta l p l ane , the Cutting edge look- 
dotted line.) (Natural size.) . , , 1 ,t- J? ogl- 

ing backward (rig. 126). I he 

point punctures the drum membrane just above and behind the 

short process of the malleus, the knife being passed upward 

and inward and a little backward, to avoid the body of the 




EXPLORATORY MYRINGOTOMY. 



473 



incus. The incision is then carried horizontally backward to 
the periphery, when the cutting edge of the knife is turned 
upward and the incision extended for a short distance along 
the superior wall of the canal (as shown by the dotted line in 
Fig. 126). This severs the numerous reduplications of mucous 
membrane and efficiently depletes this region and the lining 
membrane of the mastoid antrum. 

Exploratory Myringotomy. — When it seems desirable to 
explore the interior of the tympanum, the end is most easily 
attained by reflecting a flap of 
the membrana tympani. As the 
region demanding particular in- 
spection is that occupied by the 
incudo-stapedial articulation and 
the niches of the oval and round 
windows, the field of operation 
lies in the posterior segment. 
This has been proved to be the 
part possessing the least tactile 
sensibility, and primary incision, 
if located just within the clear 
membrane close to its posterior 
border and midway along the 
periphery, can be made with 
scarcely any pain. The knife 
should possess so keen an edge and so sharp a point that it 
will penetrate the delicate septum by its own weight. The 
puncture should be made within the clear membrane to 
avoid haemorrhage, and especial care is to be taken that 
the mucous membrane over the internal wall is not wounded, 
for the same reason. After a short incision has been made 
in this region a ten-per-cent solution of cocaine is applied to 
its margins by means of a cotton-tipped probe, after which 
the section is carried upward along the peripheral attach- 
ment to the posterior fold, then forward just below this to the 
short process of the malleus, where it again turns downward 
and runs parallel with the manubrium and posterior to it (Fig. 
127). It is usually necessary to repeat the process of anaes- 
thetizing several times before the incision is completed, but if 
this is carefully done not the slightest pain is experienced. 
The flap now falls outward and the tympanic cavity lies open 

to inspection (Fig. 136). In the great majority of cases the in- 

32 




Fig. 127. — Exploratory myringotomy. 
(Natural size.) 



474 



MIDDLE-EAR OPERATIONS. 



cudo-stapedial articulation will readily be seen, and the de- 
gree of mobility of the stapes and the amount of motion pos- 
sible at the malleo-incudal joint can be determined by manip- 
ulation with a cotton-tipped probe or by passing a delicate 
hook behind the descending arm of the incus. If the round 
window is not exposed, or if the flap does not turn readily, 
the original incision may be extended downward along the 
posterior peripheral margin as far as the inferior pole. Dis- 
placement of the flap may not expose the incudo-stapedial ar- 
ticulation and the niche of the round window in some cases, 
as these may be covered by the fold of the posterior pocket 
or by certain irregular reduplications of the mucous mem- 
brane. These folds may be so delicate that they are recog- 
nized with difficulty and yet hide completely the landmarks 
within the tympanum. If the various landmarks are not seen 
upon reflection of the flap, the sharp-pointed knife should be 
used to make one or two short vertical incisions through the 
membrane over the inner tympanic wall. The edges of the 
incisions separate, from the elasticity of the membrane, and 
the landmarks appear. The cavity having been explored and 
the indicated measures adopted, the flap may be replaced and 
held in position by a bit of thin sized paper which has been 
previously soaked in a solution of bichloride of mercury (i to 
3,000). This paper dressing is introduced into the meatus 
either on the end of a cotton-tipped probe or by means of a 
forceps, and is placed upon the surface of the drum mem- 
brane, and by manipulation made to slide over this until the 
flap is replaced, when further manipulation carries the paper 
disc over the line of incision, sealing it and retaining the 
edges in position by its adhesion to the surrounding intact 
surface. At the end of one or two days the healing process 
is complete, and the paper is subsequently thrown out by 
the outward growth of the epithelial layer of the membrana 
tympani. 

(b) Partial Myringectomy. — It is seldom possible, by the ex- 
cision of any portion of the membrana tympani or by destruc- 
tion by caustic agents, to secure a permanent opening through 
the drum membrane. When we desire to determine what 
the effect of a permanent opening would be in any given case, 
a partial myringectomy will enable us to attain this end, al- 
though the opening will usually close at some subsequent 
period. 



MULTIPLE INCISION OF THE MEMBRANA. 



475 



The operative technique consists in the excision of a flap 
which is to be formed in the manner already described in ex- 
ploratory myringotomy. If caustic agents are to be used, a 
minute drop of the concentrated sulphuric acid is applied, by 
means of a cotton-tipped probe, to the area chosen for per- 
foration, care being taken that no acid in excess of what is re- 
quired to saturate the cotton, is conveyed into the canal. The 
instrument is carried rapidly through the canal and pressed 
against the membrane for a few seconds, causing a rapid ne- 
crosis of all the layers, the affected portion becoming of a dead- 
white color. The probe easily breaks down this necrotic tis- 
sue and enters the tympanic cavity. There is but slight pain, 
and if care is taken to use but little acid there is seldom any 
reaction. The galvano-cautery may be employed in the same 
manner. Comparing these three methods, excision is un- 
doubtedly the safest plan, but it is the most difficult to ac- 
complish, the removal of the small flap being by no means 
easy. The small scissors shown in Fig. 128 will be found 




Fig. 128. — Author's scissors for middle-ear operations. 



useful in separating the flap when it is attached by a narrow 
pedicle only. When the flap can not be excised, it may be 
folded upon the outer surface of the membrane, the pedicle 
by which it is attached being made as narrow as possible. 
Unless the flap is replaced, the opening will remain patent for 
from tw r o to six weeks, during which time the conditions are 
much more favorable for observation than where resort has 
been had to undue violence completely to excise the flap, 
or where the parts have been irritated by either an escharotic 
or the actual cautery. 

(c) Multiple Incision of the Membrana Tympani. — Politzer * 
and Gruberf both propose this operation, but for exactly 
opposite conditions, the former advising it where the mem- 
brana is much relaxed as the result of the cicatrization of a 
larger perforation, while the latter employs it to relieve in- 

* Wien. med. Woch., 1871, p. 9. f Allg. Wien. med. Ztg., 1873, p. 2. 



4/6 



MIDDLE-EAR OPERATIONS. 



creased tension, the result of an inflammatory process. Gru- 
ber advises that several incisions be made from the centre of 
the membrane toward the periphery, through the dense areas, 
the adjacent incisions being connected by tranverse cuts, the 
lines of section forming the letter H. Where it seems advisa- 
ble to employ the procedure for a relaxed condition, it is neces- 
sary only to divide the cicatrix completely, or in some cases 
to excise a portion of it. It would be exceptional to find any 
permanent benefit from this operation, since the newly formed 
cicatrix must soon become relaxed. 

Plicotomy. — The posterior fold of the membrana tympani 
may be divided for the relaxation of tension, either in the 
direction of or at right angles to its long axis. When it is to 
be divided transversely the point of the knife is entered just 
above the posterior fold, midway between its posterior ex- 
tremity and the short process of the malleus. After piercing 
the membrane a quick downward stroke severs the tense band. 
In order that immediate reunion shall not take place Politzer- 
ization or inflation by means of the catheter should be prac- 
ticed daily for four or five days. 

The longitudinal section of the fold needs no special de- 
scription. The knife punctures the membrane just below the 
fold near the anterior or posterior end and divides horizon- 
tally the tissues immediately below the band. It thus severs 
any radiating fibres and relaxes the tension. 

II. Operations in which the Various Muscular or 
Fibrous Structures within the Tympanum are 
divided. 

(a) Tenotomy of the Tensor Tympani Muscles. — This proce- 
dure was proposed by Hyrtl,* although F. E. Weber f was 
the first to perform it upon the living subject. The indica- 
tions for its performance have been sufficiently stated in an 
earlier portion of the volume. 

Since in a sclerotic condition of the mucous membrane of 
the middle ear tactile sensibility is much diminished, it is 
usually stated that general anaesthesia has seldom been neces- 
sary for the performance of the operation. My own experi- 
ence has been, however, that it is less readily carried out than 
some of the more complicated procedures within the tym- 

* Topographische Anatomic f Berlin, klin. Woch.. 1871, p. 574. 



TENOTOMY OF THE TENSOR TYMPANI. 



477 



panic cavity, and I believe that in order to be successfully per- 
formed general anaesthesia should be induced in most cases. 

There are several methods of severing- the band. Weber- 
Liel, and Cholewa make use of a knife of special construction 
for dividing the tendon. In this instrument the blade is hook- 
shaped and the shaft of the knife is fixed in an angular handle 
so arranged that the knife can be rotated upon its long axis 
by the manipulation of a slide on the side of the handle. The 
technique is as follows : The membrana tympani is incised in 
front of the processus brevis, the hook-shaped knife introduced 
into the cavity, and by depressing the handle and carrying it 
somewhat forward the blade is made to press upon and par- 
tially encircle the tendon ; by rotating the blade 
the tendon is severed. To remove the knife the 
blade is rotated to its former position by revers- 
ing the manipulation. Forcible inflation by Po- 
litzer's method or with the catheter, and the 
insufflation of a little boric acid into the canal, 
completes the operation. Most commonly the 
procedure is conducted without resort to so 
complicated an instrument as the one described, 
and most operators prefer to enter the tympanic 
cavity behind the malleus handle. Gruber* ad- 
vises that the tenotome be introduced through 
the membrane in either the anterior or poste- 
rior segment, according to their relative acces- 
sibility. Schwartze, Pomeroy, and Green em- 
ploy a blunt-pointed knife curved on the flat. 
Hartmann has devised an instrument (Fig. 129) 
which is curved both on the flat and in its long 
axis, the blade being sharp-pointed, so that 
when the middle ear is entered the sharp point 
of the knife can be carried high up into the 
tympanic cavity The position of the puncture 
and the manipulation of the instrument after 
the blade has entered the tympanic cavity will 
vary according as the tendon is to be divided 
from above downward or from below upward, 
the operator is allowed considerable latitude. The technique 
depends upon the conformation in each individual case. If 



Fig. 129. — Hart- 
mann's teno- 
tome (slightly 
enlarged). 

Here again 



* Lehrbuch fur Ohrenheilkunde, Wien, 1888, p. 562. 



473 



MIDDLE-EAR OPERATIONS. 




Fig. 130. — Tenotomy of the tensor tympani. 
The knife is shown above the tendon, which 
is divided from above downward, (Natural 
size.) 



the tendon is to be divided from above downward the mem- 
brane is punctured immediately behind the short process, 
and the curved or angular blade is carried high up into the 

cavity by depressing the 
proximal end of the in- 
strument, which at the 
same time is carried a 
little backward, causing 
the blade to apply itself 
closely to the manubrium. 
The blade is then rotated 
forward and downward 
through an angle of nine- 
ty degrees, and section is 
accomplished by a slight 
sawing motion, down- 
ward pressure being ex- 
erted during the with- 
drawal of the instrument. 
As the tendon is severed 
the operator feels the resistance which it offered suddenly 
overcome, and a sharp click is frequently heard at this mo- 
ment. To divide the tendon from below upward the mera- 
brana is punctured just 
below and behind the 
short process. Upon en- 
tering the cavity the in- 
strument is advanced for- 
ward, inward, and down- 
ward, the shaft remaining 
almost horizontal, and 
the flat surface of the 
blade closely applied to 
the handle of the malleus 
until it has traversed the 
breadth of the cavity. 
The handle is then de- 
pressed, thus carrying 
the curved point of the knife high up in the tympanum. 
The instrument is then withdrawn, upward pressure being 
continually exerted and the tendon divided from below up- 
ward. The technique described presupposes the use of 




Fig. 



[31. — Tenotomy of tensor tympani 
Hartmann's knife. (Natural size.) 



with 



DIVISION OP THE ANTERIOR LIGAMENT. 



479 



Hartmann's tenotome, which, being sharp-pointed, is used 
both to puncture the membrane and to sever the tendon 
(Fig. 131.) When a blunt-pointed knife curved on the flat is 
used, the drum membrane is incised close to and behind the 
handle of the malleus with a sharp knife ; through this open- 
ing the curved knife is inserted, its concavity being directed 
toward the manubrium. The tendon is divided by depress- 
ing the handle of the knife and extending the incision upward 
toward the short process (Fig. 132.) When it seems desir- 
able to divide the tendon 
through an incision in 
the anterior segment, 
the curved knife enters 
the cavity somewhat be- 
low the short process. It 
is then advanced upward 
and backward, the flat 
surface of the blade pass- 
ing closely along the 
manubrium and severing 
the tendon as the incis- 
ion is extended. Where 
tenotomy is deemed ad- 
visable in cases of resid- 
ual purulent inflamma- 
tion, a large perforation being present, no preliminary in- 
cision is necessary, the knife being introduced through the 
existing perforation ; the tendon is severed either from below 
upward, or in the reverse direction, according to the special 
topography of the case. 

{b) Divisioii of the Anterior Ligame?it of the Malleus. — This 
measure was advocated by Politzer* in cases of marked re- 
traction of the membrana tympani, it being found in several 
instances that tenotomy of the tensor tympani alone did not 
allow the parts to resume their normal position, although this 
was possible if the anterior ligament had been severed. 

The membrane is punctured just in front of the short pro- 
cess with a short curved knife, with the cutting edge directed 
upward. The knife is carried inward almost to the bony wall, 
when the handle is depressed, crowding the edge against the 




Fig. 



132. — Tenotomy of tensor tympani from 
below upward. (Natural size.) 



Diseases of the Ear, Am. edition, Philadelphia, 1883, p. 379. 



4 8o MIDDLE-EAR OPERATIONS. 

ligamentous tissue in the anterior fold, which is divided as the 
knife is withdrawn. 

(c) The Division of AdJiesions, the Result of Suppurative or 
Nonsuppurative Inflammation. — We may divide these adhesions 
according- to their' location into two classes: 

i. Adhesions about the stapes itself. 

2. Adhesions between the malleus and incus and inner 
tympanic wall, or tense bands immobilizing the entire ossicular 
chain, the articulations between the various ossicles being 
intact. 

When the rigidity depends upon adhesions about the 
stapes itself as the result of a purulent otitis, the incudo-sta-: 
pedial articulation having been destroyed, we find the pelvis 
ovalis occupied by a mass of dense tissue which frequently 
changes the appearance completely. The head of the stapes 
may present only as a slight elevation upon the surface of the 
mass. Close inspection may reveal a preponderance of the 
newly formed tissue along the posterior margin of the pelvis, 
especially about the stapedius tendon, which can occasionally 
be seen as a bright line running through the mass. To see 
the stapes or w T hat remains of it I usually first incise directly 
downward close to the tympanic ring, so as to divide any 
bands which may tend to pull the stapes out of the visual field. 
To effect this the knife is to be carried inward just above the 
fibrous band which we wish to divide, and close to the tym- 
panic ring, until its point impinges upon the bony inner wall 
of the tympanum (Fig. 134.) It is then carried downward, the 
point being still kept against the inner wall, and severs the 
tendon of the stapedius, together with all adhesions which 
passed from the ossicle toward the posterior tympanic wall. 
This relieves the stapes from the pull of the stapedius muscle, 
and from the tension of the adhesions which have developed in 
front, it comes more clearly into view. Care should be taken 
in passing the knife inward not to carry it too far, in case the 
bony resistance is not felt at the proper depth, for fear of its 
entering the vestibule and injuring the labyrinth. After the 
posterior bands have been severed, short radiating incisions 
are made, taking the oval window as a centre from which they 
diverge. This allows the parts to retract, and by local de- 
pletion favors the formation of a thin cicatrix, in place of the 
thick fibrous deposit. The operation is completed by the in- 
sufflation of a little boric acid. It may be necessary to repeat 



DIVISION OF ADHESIONS. 



481 



this procedure several times before the desired result is ob- 
tained, since during cicatrization other adhesions may form. 
Careful attention will enable the surgeon to overcome the 
rigidity permanently in a large number of cases. 

In the second class of cases, where the entire conducting 
chain is bound down, relaxation of tension is frequently ob- 
tainable by surgical interference. In many cases a large per- 
foration is found, in the lower half of the membrane, the mar- 
gins of the perforation may adhere to the internal wall of the 
middle ear throughout ; or this condition may be confined to 
the region of the tip of the malleus handle. In these last 
cases the blunt knife, curved on the flat, should be used to 
divide the fibrous bands, or in some cases vertical incisions 
may be made through the cicatrix, or the point of adhesion 
may be taken as a centre from which these incisions shall 
radiate. 

Another condition, not uncommon, is where a consider- 
able portion of the membrane is destroyed, the remnant of 
the membrane in the upper 
and posterior quadrant be- 
ing thickened and tense, so 
that its lower border, cor- 
responding to the posterior 
fold, forms a dense fibrous 
band, crowding the under- 
lying structures firmly to- 
gether, and sometimes par- 
tially hiding the stapes or 
incudo-stapedial articulation 
from view. Section of this 
band, by an upward incision 
(Fig. 133), frequently im- 
proves the hearing ; or the 
procedure may be advisable 
as an exploratory measure, 

the retraction of the cut edges permitting an inspection of 
the structures lying in the pelvis ovalis, and revealing a con- 
dition here which may be amenable to operative treatment. 

Adhesions following a nonsuppurative inflammation will 
usually be less amenable to operative treatment than those 
developing in the residual purulent cases. The reason for 
this is that in the nonsuppurative cases the constricting bands 




Fig. 133. — Incision of cicatricial band to 
expose the incudo-stapedial articulation 
or to free the stapes. (Natural size.) 



482 



MIDDLE-EAR OPERATIONS. 



are seldom confined to any one locality, but involve the entire 
ossicular chain and the pelvis ovalis as well. The condition 
is one demanding extensive and sometimes repeated operative 
measures, and the best results are obtainable by first remov- 
ing the membrana tympani and the two larger ossicles. This 
procedure permits a thorough inspection of the pelvis ovalis 
and of the stapes, and enables the operator to resort to re- 
peated surgical procedures or mechanical measures for the 
relief of tension existing in this locality, while the primary 
operation eliminates anomalies in tension arising from other 
causes. 

III. Operations involving the Ossicular Chain. 

(a) Excision of a Portion of the Manubrium Mallei and of a 
Large Part of the Membrana was proposed by Wreden* in cases 
where it was deemed advisable to secure a permanent opening 
into the tympanum. The procedure has fallen into disuse, 
since it does not accomplish the desired end. The technique 
needs no special description, consisting merely of making a 
circular incision of the desired size by means of a sharp knife, 
the umbo being taken as the centre. After the section has 
been completed, the fibrous lamella which it encloses will be 
held by the manubrium alone, and may be removed by cutting 
through the malleus handle by means of an ecraseur, cutting 
forceps, or other appropriate appliance. 

{b) Disarticulation at the Incudo-stapedial Joint , or Division of 
the Long Arm of the Incus and Mobilizatio?t of the Stapes. — This 
procedure is of especial value in the residual purulent cases 
where the articulation is exposed, or is covered by a thin 
cicatrix only, through which it is easily visible. It is of less 
value in chronic nonsuppurative inflammation, since the open- 
ing which is made through the membrane to expose the parts 
soon closes, rendering it almost impossible for the surgeon to 
relieve by secondary operation any unfavorable results attend- 
ing cicatrization. Where the long arm of the incus and the 
posterior crus of the stapes are exposed, disarticulation is 
effected by means of the angular knife shown in Fig. 123,/ 
and g, which is inserted behind the descending process of 
the incus, and made to pass through the articulation by cut- 
ting downward. Any portion of the capsule undivided may 

* Monatsschrift fur Ohrenheilkunde, vol. i, p. 22. 



DISARTICULATION AND MOBILIZATION OF THE STAPES. 



483 



be severed by inserting the point of the knife below and cut- 
ting upward, and by hooking the knife around the anterior 
aspect of the long process of the incus and cutting downward. 
It is usually advised that the joint be opened from behind, 
the resistance offered by the stapedius muscle rendering this 
the simplest procedure. While this is theoretically correct, 
there are several objections to its performance. Frequently 
the long arm of the incus lies so near the margin of the ring 
that considerable force is necessary to introduce the knife 
behind it. If disarticulation is accomplished before the stape- 
dius muscle is divided, the retraction of this muscle may pull 
the stapes completely out of view and render subsequent mo- 
bilization impossible. It is advisable, therefore, to divide the 




Fig. 134. — Division of the stapedius 
tendon and of adhesions behind the 
stapes. (Natural size.) 



Fig. 1315. — Disarticulation at the incudo- 
stapedial articulation. (Natural size.) 



stapedius tendon and the adjacent adhesions as the first step 
of the operation. This is done by inserting a sharp straight 
knife behind and above the head of the stapes, between it and 
the tympanic ring, carrying it inward until the point touches 
the inner tympanic wall, and then cutting directly downward 
(Fig. 134). By this procedure the stapes, and hence the ar- 
ticulation, is released and brought clearly into view by the 
traction of the tensor tympani muscle and of the cicatricial 
bands situated in the anterior part of the cavity. The ante- 
rior aspect of the descending crus of the incus is now in such 
a position that the joint may be easily divided by applying 
the angular knife to it and cutting downward and backward 
(Fig. 135), or in some instances it may be more convenient to 



484 MIDDLE-EAR OPERATIONS. 

enter the joint from below, with the point of the knife, sweep- 
ing the blade anteriorly and posteriorly until the capsular 
ligament is divided. After disarticulation the process of the 
incus is pushed upward and forward to prevent reunion. 
The stapes is next examined with a probe, the most suitable 
instrument being a fine cotton holder, the tip of which is 
firmly wound with a delicate pledget of cotton. If the ossicle 
is rigid, it is to be freed by passing the pointed knife about 
the foot plate, dividing all adventitious bands which may be 
found within the pelvis ovalis, passing from its walls to the 
crura of the stapes. After incision, mechanical mobilization 
by means of the cotton-tipped probe should be effected. The 
instrument is introduced below the stapes first, and an attempt 
made to crowd the ossicle upward by a leverlike action of the 
probe. The same manipulation is repeated from above down- 
ward, from behind forward, and from before backward, care 
being taken not to fracture the crura. Where the incudo- 
stapedial articulation is ossified, the long arm of the incus 
may be divided by a stout scissors,* the fragments being sepa- 
rated so as to prevent reunion, after which mobilization of the 
stapes is carried out after the manner described. 

In chronic nonsuppurative cases Miot f advocated the 
same procedure, the structures within the middle ear being 
exposed by an exploratory incision along the posterior margin 
of the membrana tympani, as already described in the tech- 
nique of exploratory myringotomy. General anaesthesia is 
not necessary either in the residual suppurative, or nonsup- 
purative cases. 

Mobilization in the nonsuppurative cases is less effectual 
if the exploratory incision is allowed to heal than where a per- 
manent opening is maintained, either by the removal of the 
entire membrane, malleus, and incus, or by allowing the flap to 
remain displaced, although by the latter procedure it is seldom 
possible to secure a permanent perforation. The lack of success 
when the flap is replaced is due to a recurrence of the condi- 
tion, the closure of the opening rendering it impossible to deal 
with this surgically except by repeating the original operation. 

(c) Plastic Operations for the Purpose of uniting the Incus or 
the Stapes to the Membrana Tympani Directly. — The object here 

* Politzer, Archiv fur Ohrenheilkunde, vol. xxii, p. 122. 
f Revue de laryngologie, 1890, p. 49 et seq. 



REMOVAL OF THE OSSICLES. 



485 



is to exclude the two larger ossicles from the physical process 
of sound conduction, so that the sound waves falling upon the 
membrana tympani shall act immediately upon the stapes. 
Little success has attended these procedures, although in ex- 
ceptional cases they may be valuable. 

A triangular flap of the membrane is turned aside from 
the posterior superior quadrant, exposing the incudo-stapedial 
articulation ; the mobility of the incus is determined by means 
of a probe ; adhesions about the stapes are severed according 
to the rules already laid down until this ossicle and the incus 
move freely. The triangular flap is then applied directly to 
the long arm of the incus and held in place by a small pledget 
of cotton or by a small paper dressing. If the incus can not 
be freed, disarticulation at the incudo-stapedial joint is per- 
formed and the flap applied to the head of the stapes instead 
of to the long arm of the incus. 

(d) Removal of the Ossicular Chain in its Entirety, or Removal 
of Individual Ossicles. — Removal of the ossicular chain may be 
attempted either for the improvement of hearing or for the 
relief of a long-continued suppurative process, or for both 
conditions. Since the technique is somewhat different, ac- 
cording as the condition results from a suppurative or non- 
suppurative inflammation, the operative procedure applicable 
to cases where the membrana tympani is intact will first be 
described in detail, after which attention will be given to the 
particular variations demanded in cases where there has been 
destruction of the membrana tympani over a large or small 
area. We have to consider, then — 

1. Removal of the malleus and incus. 

2. Removal of the malleus, incus, and stapes. 

3. Removal of the stapes. 

If the membrana tympani is present, this is also removed 
as completely as possible in carrying out the first two Opera- 
tions, while in stapedectomy the membrane is allowed to 
remain. 

As early as 1873 Schwartze* advocated the removal of the 
malleus and the membrana tympani and disarticulation at the 
incudo-stapedial joint in cases of nonsuppurative inflamma- 
tion. Kessel f excised the membrana tympani, malleus, and 



* Arch, fur Ohrenheilk., vol. xxii, p. 128. 
f Arch, fur Ohrenheilk., vol. xiii, p. 69. 



4 86 MIDDLE-EAR OPERATIONS. 

incus, and mobilized the stapes in a case of- complete stenosis 
of the Eustachian tube, while at an earlier date he had dem- 
onstrated that the stapes * might be evulsed from the oval 
window without serious consequences. In 1885 Lucae f re- 
ported fifty-three operations in nonsuppurative otitis media 
in which the membrana tympani and malleus had been re- 
moved and the incudo-stapedial articulation divided. In six 
of these cases the incus was also taken away. From this time 
on the current literature contains numerous reports of removal 
of the ossicles in cases of nonsuppurative inflammation of the 
middle ear, the procedure being followed by varying degrees 
of success. 

Concerning the necessity of general anaesthesia, it may be 
said that at the present time the entire ossicular chain and the 
membrana tympani may be removed without the administra- 
tion of a general anaesthetic in patients having a fair amount 
of self-control. No discomfort is experienced during the en- 
tire procedure except at the moment of making the initial 
puncture, and, when the knife employed for the purpose is in 
perfect condition, the incision through the membrana tympani 
in the posterior segment just within the cartilaginous ring is 
not painful and sometimes is not felt. When the tympanic 
cavity has been entered the application of a ten-per-cent solu- 
tion of cocaine by means of a cotton-tipped probe renders the 
subsequent steps absolutely painless. It is necessary to pro- 
ceed slowly, as the local anaesthesia is confined to a limited 
area beyond the extent of the incision, and as the operation 
progresses the cocaine solution is to be applied from time to 
time to the edges of the wound and introduced into the tym- 
panic cavity through the artificial opening whenever the pa- 
tient gives evidence of feeling the manipulations in the slight- 
est degree. Naturally this prolongs the operation ; but the 
advantage gained of testing the results of the various steps 
of the operation, together with the increased delicacy of 
manipulation possible when the patient is conscious and able 
to maintain his head in any position in which it has been 
placed, more than compensates for the loss of time. 

Technique of the Removal of the Membrana Tympani and 
Ossicles when the Membrana Tympani is Intact. — With the sharp 



* Arch, fur Ohrenheilk., vol. xi, p. 199. 
f Ibid., vol. xx, p. 228. 



REMOVAL OF THE OSSICLES. 



487 



knife (Fig. 123, e) an incision is made through the membrana 
tympani in the upper and posterior quadrant, commencing 
just below the point where the posterior fold meets the tym- 
panic ring, and following this curve, is carried downward 
to about the middle of the posterior border of the ring. 
This incision is made close to the insertion of the membrana, 
but should lie entirely in the clear membrane, for the reason 
that if this is done no haemorrhage results. For the same rea- 
son care must be taken not to wound the inner wall of the tym- 
panum with the point of the knife, as any bleeding greatly ob- 
scures the field of operation and renders the succeeding steps 
more difficult. The edges of the incision are now separated 
and the incudo-stapedial articulation is usually clearly and 
easily exposed. If sufficient space is not gained, a horizontal 
incision may be made from the upper extremity of the first, 
forward toward the short process of the malleus, the section 
following the course of the posterior fold and lying just be- 
low it, thus avoiding the more vascular tissues. If this does 
not give sufficient room the 
incision may then be carried 
downward just behind the long 
process of the malleus, as in ex- 
ploratory myringotomy (Fig. 
127). In this way a flap is 
formed which, on being turned 
downward, enables the opera- 
tor to see the incudo-stapedial 
articulation clearly (Fig. 136). 
The next step is the division 
of the stapedius tendon ; this 
may sometimes be seen run- 
ning from the neck of the stapes 
backward and disappearing be- 
hind the tympanic ring ; fre- 
quently, however, the head of 
the stapes lies so close to this 
structure that the tendon can 
not be seen ; in such a case the 

pointed knife used in dividing the membrana tympani is in- 
serted close to the head of the stapes and slightly above it 
and carried inward until the inner wall of the tympanum is 
reached ; a short cut downward is then made, carrying the 




Fig. 136. — Incudo-stapedial articulation 
exposed by displacement of a flap 
from the membrana tympani. 3, 
Horizontal incision at lower portion 
of membrane ; 2, The dotted line 
indicates the incision severing the 
peripheral attachment of the mem- 
brane. (Natural size.) 



488 MIDDLE-EAR OPERATIONS. 

knife between the head of the stapes and the tympanic ring, 
while the point is still firmly pressed upon the inner wail of 
the tympanum (Fig-. 134). In this way the muscle is thor- 
oughly divided. When the tendon can be seen its division is 
perhaps more simple ; but in either case the point of the knife 
should be firmly pressed against the inner wall of the tym- 
panum, in order that the tendon and any adhesions about it 
may be thoroughly and completely severed. 

As soon as this has been done the action of the tensor tym- 
pani will bring the incudo-stapedial articulation and the stapes 
more clearly into view. The next step is the division of the 
incudo-stapedial articulation which is effected with the angu- 
lar knife. The knife is inserted into the handle in such a way 
that the point is directed backward and is carried into the 
tympanic cavity in front of the long arm of the incus, and the 
blade passed to the inner side of this process (Fig. 135)1 by 
slight pressure backward the shaft of the instrument is kept 
close to the descending process of the incus, while at the 
same time the instrument is pressed inward, so that the an- 
gular blade will lie against the internal tympanic wall ; the 
articulation is divided with a downward stroke. If fibres of 
the capsular ligament still remain undivided posteriorly the 
angular knife is to be turned in an opposite direction, with 
the point directed forward, when, by passing it behind the 
long process of the incus, a downward stroke will complete 
the division. 

If these steps have been carried out as indicated it will be 
the exception if more than a drop of blood has been lost. 

Next, with the pointed knife, a short, horizontal incision is 
made through the membrana tympani at its most dependent 
part close to the insertion into the annulus tympanicus (Fig. 
J 3^ 3)i the pointed knife is quickly laid aside and the probe- 
pointed knife (Fig. 123, c) is inserted, and the membrane is 
divided along its posterior periphery from below upward 
until the exploratory incision is encountered. In the same 
manner the anterior segment of the membrane is divided from 
below upward with the probe-pointed knife, the incision ex- 
tending as far as, but not into, Shrapnell's membrane. (The in- 
cision is indicated by the dotted line, 2, in Fig. 136.) Up to 
this point no blood has been lost and the field of operation 
is as clear as when we started. There remains to be divided 
the membrana flaccida and the ligaments which bind the mal- 



REMOVAL OF THE MALLEUS. 



489 



leus externally, in front and behind. The pointed knife is 
again used for this section, which should be made rapidly. 
The knife is held so that the flat surface of the blade looks 
toward the roof of the canal, the cutting edge being directed 
backward ; the point of the knife is entered just above the 
short process of the malleus and is pushed inward and up- 
ward, the handle being depressed so that the shaft often 
touches the margin of the speculum. In this manner the 
knife is made to enter the fornix tympani ; it is now made 
to cut its way out, downward and backward, thus severing 
the external and posterior ligaments of the malleus and di- 
viding the membrana flaccida posteriorly. The knife is then 
quickly turned and made to cut in the opposite direction, 
being carried forward over the short process, dividing the 
anterior segment of the membrana flaccida, some fibres of 
the external ligament, and the strong anterior ligament of the 
malleus. The malleus is now held only by the superior liga- 
ment and the tendon of the tensor tympani, neither of which 
is strong. The haemorrhage from the last incision may be free 
and may obscure the field, but usually, owing to the elevated 
position of the head, the upper part of the field is not obscured, 
and the short process of the malleus can be distinctly seen. 
The ossicle is quickly grasped with the forceps (Fig. 137), just 
below the short process, and by pressing inward to dislodge 




Fig. 137. — McKay's ear forceps. (The blades 
should be about half an inch longer than in the 
forceps usually sold under this name.) 



the neck of the bone from the projection upon which it rests, 
followed by traction downward and then outward, the ossicle 
is extracted. No force is required to rupture the tendon of the 
tensor tympani or the superior ligament, as they offer very lit- 
tle resistance. 

It will be necessary now to wipe out the blood which has 
followed the removal of the malleus, but in most cases a single 
pledget of cotton will dry the cavity completely. The incus 

33 



490 MIDDLE-EAR OPERATIONS. 

is next sought for, and, if in sight, is grasped with the forceps 
and removed, traction being at first exerted downward and 
forward and then outward. Most frequently when the incus 
is in view the long process will be seen, not in the normal 
location, but lower down and lying close to the border of the 
tympanic ring — so close, frequently, that it is overlooked, for 
it then apparently constitutes a part of the ring. Manipula- 
tion by means of a probe reveals its identity and the ossicle 
can be extracted in the manner already described. This dis- 
placement of the incus downward and backward is due to the 
fact that in the removal of the malleus the capsular ligament 
binding the two ossicles together must be ruptured. The 
incus itself is attached to the tympanic wall by means of a 
single ligament running from its short process to the walls of 
the fornix tympani. Traction downward on the malleus dis- 
places the incus downward and also revolves it backward, the 
short process being the fixed point. Thus frequently, after 
the malleus has been removed, careful inspection of the field of 
operation fails to reveal any trace of the incus, it having been 
rotated entirely out of sight behind the tympanic ring. To 
effect its extraction is not always easy, and yet in cases where 
there has been no suppuration it will rarely happen that the 
ossicle will escape. When not in sight the long process of the 
incus can be easily brought into view by means of the incus 
hooks (Fig. 123, j and k). These hooks are curved in oppo- 
site directions for the. right and left ear, the concavity of the 
curve looking anteriorly in each case ; the instrument is in- 
serted into, the handle with its angular extremity directed 
upward. The incus hook is introduced into the tympanic 
cavity and the angular portion passed behind the tympanic 
ring close to the floor of the canal, the hook being inserted 
in such a way that the concavity of the hook looks upward. 
When the angular portion of the instrument has entirely dis- 
appeared behind the ring the instrument is drawn outward 
until it is felt to press closely upon the inner surface of the 
tympanic ring, when it is rotated forward, at the same time 
being carried a little upward. Usually this manipulation 
swings the long arm of the incus into view (Fig. 138). The 
difficulty sometimes experienced in securing the incus usu- 
ally lies in the fact that the operator is inclined to search 
for the ossicle too high up in the tympanum and to forget 
that the long process lies close to the margin of the ring ; 



REMOVAL OF THE INCUS. 



491 




Fig 



-Incus hook in 
(Natural size.) 



position. 



the hook is therefore frequently carried too deeply into the 
tympanic cavity and fails to engage the long process. This 
manoeuvre is to be repeated several times in case the first effort 
is not successful. If no free body 
is felt with the hook it is then 
inserted into the tympanum at 
the anteroinferior portion with 
the concavity of the hook di- 
rected posteriorly ; the hook is 
now rotated, sweeping the ex- 
tremity which touches the tym- 
panic ring closely, backward, 
and at the same time somewhat 
upward. This manipulation will 
bring the incus into view in case 
rupture of the posterior ligament 
of the incus during the removal 
of the malleus has allowed the 
ossicle to fall into the antero- 
inferior part of the tympanic cavity, an accident which may 
sometimes happen. 

If the ossicle is not found in either of these situations, the 
hook should be swept upward and forward through the pos- 
tero-superior and superior portions of the tympanic cavity, 
keeping it still pressed firmly against the internal margin of 
the ring. Care is to be taken in this manipulation that the 
hook does not pass between the crura of the stapes or frac- 
ture them as it is carried forward. If the incus still remains 
hidden, the hook having the opposite curve should now be 
carried into the fornix tympani with the concavity directed 
backward, the angular portion of the instrument being 
hooked behind the inner extremity of the superior wall of 
the meatus. The instrument is now rotated backward, and 
at the same time is carried downward, rotation being con- 
tinued through an angle of one hundred and eighty degrees. 
This manipulation will dislodge the incus in cases where its 
posterior ligament is very strong, or where the long process 
has been rotated far backward out of reach of the hook. 
After this downward sweep it is well to repeat all of the 
steps for dislodging the incus in the order named, as this last 
manipulation may displace the ossicle downward, although it 
may still remain hidden from view. The objection to begin- 



492 



MIDDLE-EAR OPERATIONS. 



ning the search in the manner last mentioned lies in the fact 
that, if the ossicle is already free or nearly so, the manipula- 
tion is apt to displace it so far toward the mastoid antrum as 
to render it entirely inaccessible. I have written upon the 
method of extracting this ossicle somewhat at length, because 
I believe it to be extremely important to remove it if pos- 
sible ; and I feel certain that the advantages gained by its 
extraction are more than enough to warrant prolonging the 
operation for this purpose. 

After the incus has been removed, the cavity is thoroughly 
dried and the region of the round window inspected. Any 
thickening in this situation should be overcome by cutting 
away the hypertrophied tissue.if possible. Usually, however, 
we find simply a thickening of the mucous membrane about 
the fenestra. Stellate incisions by means of an angular knife 
(Fig. 123, f and g,), introduced into the niche, most frequently 
relieve the tension. 

The stapes is next inspected and its mobility tested. If 
rigid, all adhesions about it should be divided and the ossicle 
mobilized with the cotton-tipped probe, in the manner already 
described ; if its motion is now free, the operation may be 
considered completed. If, on the other hand, the motion of 
the stapes is still impeded, or if the adhesions have been found 
to be so extensive that, after they have been divided, cica- 
trization will probably render the ossicle rigid again, the 
stapes may be removed. All soft tissue binding it down 
should be carefully severed with the sharp knife passed 
around the foot plate, after which a delicate hook (Fig. 123, 
b) is passed between the crura and the ossicle is removed by 
traction. It is often more easy to grasp the head of the bone 
with the forceps and remove it in this way than by making 
use of the hook. 

In cases where difficulty is experienced in finding the 
incus, and it is deemed necessary to remove the stapes — this 
ossicle being easily seen — it is often wise not to delay the 
removal of the stapes until the incus is found, since, in the 
manipulations necessary to displace the incus, the crura of 
the stapes might accidentally be broken or the head of the 
bone be so displaced as not to be easily seen. Hence, if the 
incus is not readily found, and it has been found advisable to 
extract the stapes, this may be removed as the second step 
of the operation, and the incus subsequently searched for. 



REMOVAL OF THE INCUS. 



493 



If the stapes is removed at this stage of the procedure, care 
must be taken in searching for the incus that the incus hook 
is not passed through the oval window, thus, injuring the 
labyrinth. This may seem a needless precaution ; but any 
one who has studied the parts upon the cadaver will appre- 
ciate how easily the incus hook can be passed through the 
thin membrane covering the fenestra ovalis. The reason of 
this lies in the fact that the plane of the oval window is not 
vertical, but inclined downward and outward. When this 




Fig. 139. — Author's cutting forceps for the removal of a portion of the inner ex- 
tremity of the external auditory canal. 

opening is situated high up, and is almost hidden by the tym- 
panic ring, the incus hook may be easily carried under its 
upper margin and through the membrane covering the open- 
ing, the operator mistaking the resistance offered for that of 
the tympanic ring. If the posterior wall of the canal is closely 
followed and the incus hook made to enter the tympanum 
low down, and is afterward applied closely to the tympanic 
ring, this accident can not occur. 



494 MIDDLE-EAR OPERATIONS. 

In some instances the margin of the tympanic ring hides 
the stapes so completely that this ossicle can not be seen, and 
it is impossible to form an intelligent opinion as to its condi- 
tion or to effect its removal. In such an event the margins 
of the ring in this situation may be cut away by means of the 
forceps shown in Fig. 139. This forceps is so constructed 
that when open the distal extremity of the lower blade can 
be passed up behind the tympanic ring. Upon closing the 
instrument, the chisel blade cuts away a small chip from 
the overhanging wall. By repeating this procedure enough 
space can be gained to permit of access to the stapes and 
oval window. 

Occasionally the foot plate of the stapes will be found to 
be so firmly fixed in the oval window that it can not be loos- 
ened, and that after dividing all adhesions its removal is im- 
possible, the crura sometimes being broken in the attempt at 
extraction. In such an event the operator should proceed 
with the greatest caution. All the soft tissues should be care- 
fully removed from the oval niche by means of the angular 
knives (Fig. 123, f, g) and a delicate curette (Fig. 123,0). If 
the outline of the foot plate can now be made out, a pointed 
knife should be carried around its periphery in the hope of 
making an opening at some point where the union is less firm ; 
through such an opening a delicate hook can be introduced 
and a part at least of the foot plate brought away. It com- 
plete ossification has taken place I should advise the cautious 
use of a small guarded drill, which might be made to perforate 
the foot plate at its centre, after which portions might be re- 
moved with the hook. I have never had occasion to do this 
upon the living subject, but should not hesitate to do so, 
using, of course, great care. It would be possible to carry 
out this step without evacuating the perilymph ; but even if 
a small quantity of the fluid should be lost, Kessel's observa- 
tions have proved that no harm results. It need hardly be 
said that such interference is justifiable only in cases where 
absolute asepsis has been preserved. 

After all the operative steps deemed necessary have been 
carried out, the cavity is to be dried with pledgets of cotton 
and a tampon of iodoform gauze or a long pledget of cotton in- 
troduced. This is carried completely into the tympanum and 
should fill the canal but loosely. The object of the gauze is 
to check any oozing which may occur and to serve as a drain, 



TREATMENT AFTER OPERATION. 495 

thus preventing- the formation of a blood clot within the mid- 
dle ear; if this is allowed to form it may give rise to consider- 
able pain by preventing the escape of secretion during the first 
days after the operation. If there is much pain a few hours after 
the operation this tampon is removed and the ear is douched 
with a warm, weak antiseptic solution (as, for instance, a satu- 
rated solution of boric acid or a solution of bichloride of mer- 
cury, i to 8,000), after which the tampon is reinserted. When 
the odor of iodoform is objectionable, sterilized or borated 
gauze may be used. This second tampon is allowed to remain 
in position for twenty-four hours, and in cases where there is 
no pain after the operation the first tampon is not disturbed 
for twenty-four hours. This tampon is placed so deeply as to 
be out of the reach of the patient, while a pledget of cotton is 
placed at the orifice of the meatus to collect any serous transu- 
date. The patient is allowed to change this outer pledget as 
often as it becomes saturated, but leaves the deeper one undis- 
turbed. The subsequent treatment depends upon the amount 
of local reaction following the procedure. If there is but lit- 
tle discharge, the cleansing- of the ear once daily by the sur- 
geon, followed by the insufflation of boric acid, dermatol, or 
some kindred powder, will be all that is necessary. If the 
mucous membrane over the internal tympanic wall appears 
healthy and there is little or no secretion, the best results w T ill 
be obtained by keeping the canal aseptic by gently wiping the 
walls with a solution of bichloride of mercury (1 to 5,000) in 
fifty-per-cent alcohol, leaving- the tympanic cavity undisturbed. 
If any powder is insufflated it should in these cases be applied 
to the walls of the canal only, and should not enter the tym- 
panum. When the middle ear is not inflamed, any interfer- 
ence retards the progress of the case rather than favors it. If 
the patient can not be seen daily, as is usually the case in dis- 
pensary practice, gentle syringing of the ear once or twice 
daily, according to the amount of discharge, if any appears, is 
all that will be required, but I have never thought it wise to 
trust the insufflation of any powder to the patient. When the 
discharge is only slight, even the syringing is objectionable, 
and an intelligent patient may be allowed to cleanse the ear 
by simply wiping it out with a pledget of cotton wound upon 
an appropriate cotton holder. On the other hand, if at the 
end of a week there is still considerable secretion, the patient 
is directed to instill a few drops of a solution of boric acid in 



496 MIDDLE-EAR OPERATIONS. 

alcohol of a strength of twenty grains to the ounce, after each 
syringing. The amount of discharge after the operation will 
depend upon the habit of the patient and also upon the condi- 
tion of the mucous membrane of the tympanum. In cases of 
advanced sclerosis the amount is frequently insignificant, espe- 
cially if the patient is not of a full habit. On the other hand, 
when the tympanic cavity or the fornix tympani has been full 
of connective tissue rich in blood vessels, the discharge fol- 
lowing the operation will be more profuse. It is probable, 
also, that prolonged manipulation within the cavity at the time 
of the operation favors a more profuse discharge, although 
this is certainly not true in all cases, and should not deter the 
operator from doing a deliberate and thorough operation. 

I have written somewhat at length about the management 
of the cases after operation because I consider this an impor- 
tant point. In a general way, the less that is done after the 
operation, the more likely we are to obtain a permanent open- 
ing into the tympanic cavity, a condition always to be desired. 
Hence the aim should be to keep the ear clean with as little 
manipulation as possible, and to avoid the use of astringents 
or caustics to stop the discharge, since they will certainly pro- 
mote the reproduction of the tympanic membrane. 

The amount of disturbance caused by the procedure de- 
scribed is very slight. Of forty cases, both purulent and non- 
purulent, thirty-five left the hospital twenty-four hours after 
the operation and resumed their regular daily work without 
the least trouble, and quite a number returned home upon the 
evening of the same day, the operation having been performed 
in the afternoon. Of course the stapes was not removed in all 
of these cases ; and when this ossicle is taken away I prefer to 
confine the patient to the house for twenty-four hours at least. 
Yet in three cases of stapedectomy the patients returned 
home in less time than this without any unpleasant effects, 
while in two cases in which this ossicle was left in situ, but 
had been subjected to considerable manipulation in securing 
the incus, dizziness persisted for several days after the opera- 
tion. As a rule, when the two larger ossicles alone are to be 
excised, the patient can be assured that any disturbance suf- 
ficient to incapacitate him for work will not last more than 
twenty-four hours — an item of importance among those who 
find it impossible to obtain a longer respite from their daily 
vocation. Of this we can be as certain as in allotting the same 



REPRODUCTION OF THE MEMBRANE. 497 

period for the disappearance of the unpleasant effects of gen- 
eral anaesthesia, and the surgeon is justified in promising that 
the effects of the operation will not detain the patient after the 
disturbance due to the anaesthetic has passed away. 

When the stapes is to be removed, however, the dizziness 
may make locomotion difficult for a somewhat longer period, 
and if there is a probability that this will supervene it is not 
wise to promise that this giddiness will not interfere with lo- 
comotion for several days, although in many cases the giddi- 
ness will disappear rapidly. If the malleus and incus alone 
are removed it will be decidedly rare for any such disturb- 
ance to follow. 

, I have never met with pain or severe local inflammation as 
the result of these operations, for the reason, I believe, that 
perfect drainage exists. In this respect I feel certain that the 
complete removal of the ossicles and membrane commends 
itself, when compared with some of the intratympanic opera- 
tions in which less positive violence is done but in which free 
drainage is not secured. 

As regards the partial or complete reproduction of the 
membrana tympani, my experience has been that, as a rule, 
the membrane will reform, although this is not always the 
case. In dealing with this result the removal of the two larger 
ossicles is of great advantage. The membrane which reforms 
is usually thin and not as sensitive as the normal membrane, 
and its removal is but a trivial measure both for the patient 
and surgeon. Again, its reproduction does not always impair 
the result of the operation. In cases, however, in which, after 
the membrane has been reproduced, the hearing becomes 
worse than while a perforation was present, it should be re- 
moved. General anaesthesia, in my experience, has never been 
necessary. The first incision through the membrane is slightly 
painful, after which a few drops of ten-per-cent aqueous solu- 
tion of cocaine introduced into the tympanic cavity by means 
of the cotton-tipped probe renders the remainder of the op- 
eration painless. The operation is best performed by passing 
the straight knife (Fig. 123, e) through the membrane close to 
the tympanic ring and just below the head of the stapes and 
dividing the posterior attachment of the membranes close to 
the ring for a short distance, great care being taken not to 
wound the mucous membrane of the tympanum. The probe- 
pointed knife should then be substituted and the attachment 



MIDDLE-EAR OPERATIONS. 

followed downward to its lowest point. It will then be found 
that the tissue is so relaxed that division of the anterior at- 
tachment is difficult ; to overcome this the sharp knife is again 
passed through the membrane at its lower part just in front 
of the point where the posterior incision terminated. A little 
pain is usually experienced from the incision, but it is only 
momentary. The anterior attachment is now divided from 
below upward with the blunt knife until the incision meets 
that which severed the posterior attachment. Usually the re- 
laxation interferes with the complete section. The membrane 
is now held by a thin strip of tissue above and below. A touch 
with the sharp knife severs these attachments or weakens them 
to such an extent that the entire membrane may be easily re- 
moved with the forceps. If it is too firmly held, the small scis- 
sors (Fig. 128) will be found useful. The procedure is so sim- 
ple that, if attention is given to secure an aseptic condition of 
the instruments and field of operation, no reaction results. The 
operation may safely be performed at the office of the physi- 
cian and the patient at once allowed to resume his usual duties. 
It is well to protect the ear by the insertion of a cotton pledget 
which need not be worn for more than forty-eight hours after 
the removal of the new membrane. After this it is well for 
the patient to occlude the meatus with a cotton pledget when 
out of doors. At the end of five or six days no protection is 
necessary. The patient should be cautioned against taking 
cold ; but further than this no special precautions are to be 
advised. The procedure is not likely to be followed by any 
discharge, and all syringing of the ear is to be avoided unless 
pain or profuse discharge supervene, as disturbing the parts 
in any way may excite enough reaction to cause a reproduc- 
tion of the membrane. 

One point is worthy of special attention, and that is that 
the removal of a membrane which has formed after operation 
should not be undertaken until all traces of inflammation have 
disappeared. The surgeon must wait until the newly formed 
tissue is pearly white and glistening and until the mucous lin- 
ing of the tympanum has also assumed its normal condition, 
as evidenced by the absence of redness, engorgement of its 
vessels being easily made out through the thin cicatricial mem- 
brane. If this rule is not observed the operation will be more 
painful, and reproduction is almost certain. If the membrane 
reform again, a second or third removal is still more simple, as 



TREATMENT OF SECONDARY MEMBRANE. 499 

the density of the tissue is less each time that it is reproduced. 
In one case this was so marked that after the first incision the 
edges of the wound retracted so widely that it was possible 
to remove only a minute portion of the neW-formed tissue, and 
yet the tympanum was freely exposed, and no reproduction 
has followed at the end of several months. 

In plethoric individuals a persistent reproduction of the 
membrana tympani after excision can be prevented by a re- 
striction of the diet for a few weeks previous to and following 
the secondary removal of the structure. This is suggested 
by Sexton,* and I have proved its efficacy. 

In certain instances it may be found that the new mem- 
brane has become adherent to the inner wall of the tympa- 
num, thus rendering its complete removal difficult. In one 
such case in which the stapes had been left in situ, the hearing 
remaining impaired, apparently on account of the stapes being 
bound down by the newly formed membrane, this was divided 
first behind the head of the stapes and the incision was car- 
ried downward close to the tympanic ring for a distance 
equal to about one third its posterior margin. The stapes 
then lay free, while in front there was a flap attached by adhe- 
sions to the inner tympanic wall ; this flap was turned forward 
and the underlying wall of the tympanum was scarified, after 
w r hich the flap was replaced and pushed down upon the wall 
of the middle ear, care being taken 'that the free margin lay 
below the tympanic ring. Adhesion at once resulted, leaving 
the stapes projecting into the canal, while the tympanic cavity 
was largely obliterated from the adhesion of the membrane to 
its inner wall. Thus the middle ear was thoroughly protected 
by a cutaneous covering, while the parts essential to audition 
remained accessible for further operative procedure. The 
patient, though better, is still under treatment, and I hope for 
still further improvement following the division of remaining 
bands which partially fix the stapes. It may be advisable in 
certain cases to preserve the anterior portion of the membrana 
tympani in removing the malleus and incus, and, after scarifi- 
cation of the inner wall of the tympanum, to attempt to secure 
adhesion of the anterior segment of the membrana to this 
structure. In this manner we might shut off the anterior 
part of the tympanic cavity from the posterior portion which 

* The Ear and its Diseases, New York, 1889, p. 392. 



500 MIDDLE-EAR OPERATIONS. 

contains the parts especially concerned in audition. The pos- 
terior portion would become covered by epithelium from 
the surface of the membrana tympani, and the objection of 
having an exposed mucous surface would be avoided. We 
could by care secure a thin epithelial covering for the round 
and oval windows, the stapes being removed or not, according 
to indications. I have never performed the operation with 
this object in view, but, from the fact that Nature occasionally 
succeeds in doing this unaided, it may not be out of place to 
suggest it here as worthy of a trial. 

Technique of Operation where the Membrane is Partially or 
almost Completely Destroyed, — Where the ossicles are to be re- 
moved for the relief of a purulent inflammation general an- 
aesthesia should be employed, since removal of the ossicles 
alone constitutes but a small part of the operation. The 
pathological process is seldom confined to these structures, 
but has involved as well the bony walls of the tympanic cav- 
ity, and it becomes necessary to curette thoroughly the entire 
space if the process is to be permanently checked. In these 
cases also the malleus and incus are frequently destroyed in 
large part, nought but minute fragments remaining. To se- 
cure these fragments, prolonged, and sometimes forcible, ma- 
nipulation becomes necessary, and a thorough operation is 
possible only under general anaesthesia. 

When a purulent inflammation has resulted in the destruc- 
tion of a considerable portion of the membrana tympani, the 
method of procedure must be modified to a certain extent. 
In some of these cases we shall find the lower portion of the 
membrana wanting, the membrana flaccida thickened and 
highly vascular, binding the ossicles down and concealing 
them more or less completely. We may be able to recognize 
by inspection only the prominent short process of the malleus 
and a portion of the manubrium, the latter lying almost hori- 
zontal, its tip bound firmly to the upper part of the inner 
tympanic wall. Behind the short process examination with a 
probe reveals the incus and stapes as present, but whether in 
their entirety or not Can not be determined. In other cases, 
while there may have been extensive destruction of the mem- 
brana tympani, the posterior superior segment is covered with 
a thin cicatricial membrane, through which the incudo-stape- 
dial articulation is plainly seen, or this joint may be com- 
pletely exposed, no covering being present. My rule has been, 



TECHNIQUE IN SUPPURATIVE CASES. 501 

in all cases where the incudo-stapedial articulation is visible, 
or where this region is covered by a nonvascular membrane 
the division of which will not lead to annoying haemorrhage, 
to divide first the stapedius muscle and then the incudo- 
stapedial articulation in the manner described when consider- 
ing the method of operation in cases in which the membrana 
is intact. When, however, it is evident that an incision in 
this region will be followed by haemorrhage, such a step serves 
only to complicate the operation, as the bleeding will render 
it impossible to see the incudo-stapedial joint, much less to 
disarticulate with certainty, and will frequently completely 
obscure the field of operation, hiding even that most promi- 
nent and important landmark, the short process of the mal- 
leus, so that considerable difficulty may be experienced in 
removing even this ossicle. Experience shows us that when 
this condition is present there is very little haemorrhage after 
the membrana flaccida has been completely freed from its 
attachments and removed, together with the malleus. Our 
first step, then, will be to insert the straight pointed knife 
above the short process, pushing it inward and upward until 
the inner wall of the tympanum is encountered ; it is then 
made to divide rapidly the attachments of the remnant of the 
membrane to the tympanic ring by directing its edge back- 
ward and incising close to the margin of the ring ; without 
removing it from the wound, the edge is turned in the oppo- 
site direction and divides the anterior attachments. In cut- 
ting backward, the operator must bear in mind that the in- 
cudo-stapedial articulation has not been severed, and in this 
region as little force as possible should be used. For this 
reason, also, the posterior incision should be made first as 
above directed. Almost immediately the fundus of the canal 
fills with blood, but for a few seconds at least the short pro- 
cess is plainly visible ; and if examination has shown us that 
the manubrium is not firmly bound to the promontory, the 
malleus is at once seized with the forceps just below the short 
process and removed in the manner already described. If, 
however, firm adhesions are known to exist, or if the mal- 
leus is found -to be firmly fixed on grasping it with the for- 
ceps, no force should be used to effect its removal, but the 
canal should at once be tamponed firmly with cotton by car- 
rying an elongated plug into the tympanic cavity with the 
forceps and pressing it firmly upon the tympanic wall, the 



502 



MIDDLE-EAR OPERATIONS. 



remainder of the plug being then forced inward. Upon 
this tampon a second and third are crowded until there is no 
bleeding about the plugs. If this packing is allowed to re- 
main in position for a few moments and then removed with 
the forceps, the field of operation will be found to be dry, the 
bleeding having been entirely checked. Any given area can 
be more completely cleansed by touching it with a small 
pledget wound upon a cotton-holder. The adhesions binding 
the malleus to the promontory can now be divided with the 
blunt knife curved on the flat, after which the ossicle is re- 
moved by means of the forceps. If the malleus is still firmly 
fixed, manipulation by means of the probe will determine the 
situation of the undivided attachments and their section can 
be effected. 

When it has been possible to divide the incudo-stapedial 
articulation as the initial step, I frequently remove the malleus 
in the manner described as the second step of the operation, in 
place of the first, after freeing the remnant of the membrane 
from its peripheral attachments below, anteriorly and posteri- 
orly. This, of course, applies to cases in which the greater por- 
tion of the tympanic membrane has been destroyed. When 
only a comparatively small portion of the membrana vibrans is 
wanting and excision is deemed proper, it may be well, after 
dividing the incudo-stapedial articulation, to sever the pe- 
ripheral attachments of the membrane from below upward by 
means of a blunt knife introduced through the perforation. 
As a rule, however, so many adhesions exist between the 
inner tympanic wall and the lower portion of the membrana 
that such a procedure is unadvisable. Moreover, the parts 
are frequently so vascular that the attendant bleeding may 
complicate the more important part of the procedure — the 
division of the superior attachments and the removal of the 
malleus. It is usually wiser in these cases to divide the upper 
segment first, the knife being carried into the perforation in 
terminating the posterior and anterior incisions. 

It may seem hazardous to subject the stapes to the possi- 
bilities of violence attendant upon removal of the malleus be- 
fore the incudo-stapedial articulation has been divided. A 
moment's reflection will convince one, however, that the 
presence of firm connective tissue which renders the proce- 
dure necessary also fixes the stapes so firmly that intelligent 
manipulation can scarcely displace it, while the danger of in- 



OBSTACLES TO THE REMOVAL OF THE INCUS. 



503 



flicting such an injury is much greater if an attempt is made 
to divide the articulation with the field of operation partially 
obscured by blood. Again, it frequently happens that the 
long process of the incus has become necrotic and the articu- 
lation has been destroyed, so that no connection between the 
two ossicles exists. 

After the malleus has been removed, the stapedius muscle 
and incudo-stapedial articulation should be found and divided, 
unless this step has already been performed, after which 
search is made for the incus in the manner already fully de- 
scribed. It should be remembered that as caries more fre- 
quently attacks the incus than any other ossicle, it may be 
partially or completely destroyed. In the former case its re- 
moval is often difficult, while it is important to determine with 
certainty the latter condition, to avoid a prolonged search if 
it is absent. It should also be borne in mind that the patho- 
logical process may have resulted in a bony union between 
the incus and malleus, and that both ossicles may be extracted 
together. In case both ossicles were intact, the operator could 
not overlook such an occurrence ; but when one or both have 
been partially destroyed, careful inspection of the portions re- 
moved may be necessary, to determine the simultaneous re- 
moval of the malleus and incus. The operator should then, 
upon extracting what he supposes to be the malleus, carefully 
examine it, in order to assure himself that the body of the incus 
is not attached thereto. If nothing but the malleus is found, 
the field of operation should be dried and inspected carefully. 
If no portion of the incus is seen, special attention should 
next be given to the postero-superior segment of the field. It 
sometimes happens that the incision has not been close to the 
tympanic ring in this region, a circumstance not easily recog- 
nized unless the parts are touched with the probe, when it will 
be found that a small curtain, or flap, of tissue remains undi- 
vided. The destruction of a small part of the ring at this point, 
as the result of caries, also gives rise to a similar appearance. 
It quite frequently happens that the incus is adherent to this 
flap, or completely concealed by it. Division of the soft parts 
close to the bony margin will, in such a case, bring the incus 
into view. If not found in this situation, the ossicle must be 
searched for with the incus hook, in the manner already de- 
scribed while considering the operation in cases with an 
intact membrana tympani. If all of these manipulations fail 



504 MIDDLE-EAR OPERATIONS. 

to bring- the incus into view, or if it has not been felt, and the 
incus hook can be carried freely from behind forward, through 
the vault of the tympanum, the operator may decide that the 
ossicle has been destroyed by caries, or that it has suffered 
partial destruction, and the remaining portion has become 
amalgamated with the tympanic roof. If, however, it has 
been seen or felt at any time, its subsequent loss will mean 
dislocation into the mastoid antrum.. 

The management of the stapes and the region of the round 
window is conducted in the mariner already described. 

Any parts of the membrana tympani which may remain in 
the lower portion of the fundus are to be removed with the 
knife, curette, and forceps if they are the seat of a hypertrophic 
process, as evidenced by considerable thickening and increased 
vascularity, for they may conceal areas of bony necrosis. If, 
however, the appearance of the lower portion of the mem- 
brane is healthy, we may feel certain that the bony structures 
are unaffected, and that there is no indication for the removal 
of the lower portion of the membrane — in fact, its presence 
will hasten cicatrization. 

After drying the tympanum thoroughly, we should next 
search for softened bone, both by inspection and with the 
probe. Inspection will often reveal here and there unhealthy 
granulation tissue indicative of the presence of dead bone. 
The probe should be made to traverse carefully the entire 
inner wall of the tympanum, and should also be bent at a 
right angle at the tip, to enable the surgeon thoroughly to 
explore the tympanic vault. The curette should then be 
freely used, and all granulation tissue and softened bone 
should be removed. For the atrium the straight curette 
(Fig. 123 a) will be found serviceable, but for the vault the 
sharp spoons, bent at a right angle (Fig. 123 h, i), must be called 
into requisition. This procedure of thoroughly removing ex- 
uberant granulations and curetting the walls of the entire cav- 
ity is of the greatest importance, and should be conducted 
with special care, as the ultimate success of the operation 
often depends quite as much upon this step as upon the re- 
moval of the ossicles. An area of softened bone in the vault 
of the tympanum will keep up the discharge for a long time, 
and render the result of the operation far from satisfactory. 
Hence quite as much attention should be given to this proce- 
dure as to the removal of the ossicula. After the bony walls 



TREATMENT AFTER OPERATION. 



505 



of the tympanum have been thoroughly curetted, the margins 
of the tympanic ring should receive attention. It frequently 
happens, when long-continued suppuration has existed, that 
the margin of the ring becomes involved. This is particularly 
true of the superior and postero-superior margin, on account 
of its intimate relation to the ossicula, and because it forms a 
portion of the floor of the vault of the tympanum. Any 
roughness or softening in this region should be dealt with 
radically. All diseased areas should be removed with the 
curette, and a portion of the ring may be excised with the 
cutting forceps if necessary. 

After all these steps have been carried out, the treatment 
of the case for the first twenty-four hours will not differ from 
the after-treatment of cases in which the membrana tympani 
was originally intact. The treatment subsequent to the first 
twenty-four hours, however, must vary with each individual 
case. While the discharge continues profuse, the ear must be 
cleansed by the patient with the syringe and a mild antiseptic 
solution twice daily, or more frequently if this is necessary to 
keep the parts clean. At the end of a week, if there is con- 
siderable discharge, I recommend the instillation of the solu- 
tion of boric acid in alcohol twice daily after thorough cleans- 
ing. Any granulation tissue must be destroyed, as it appears, 
by means of chromic acid, silver nitrate, the actual cautery, 
or any other destructive agent. If it is found that all carious 
bone has not been removed, lactic acid, applied to the affected 
areas by means of a cotton-tipped probe, is frequently suffi- 
cient to determine the formation of healthy granulation tissue 
and effect complete cicatrization. The concentrated acid 
should be used, and should be thoroughly rubbed into the 
tissues. As the discharge becomes almost nil we may dis- 
pense with the syringe, and the patient may be allowed to 
cleanse the ear by means of pledgets of cotton wound upon 
any convenient probe, while the surgeon may once or twice 
weekly insufflate a small quantity of boric acid, dermatol, or 
other mild antiseptic or stimulating powder, until all dis- 
charge ceases. It has been my good fortune in all such cases 
either to stop the discharge completely or to diminish it so 
much that it has ceased to be a source of annoyance. The 
length of time which must elapse after the operation before 
complete cessation of the discharge must vary with each 
case, depending upon the extent of the original involvement. 

34 



506 MIDDLE-EAR OPERATIONS. 

From six to eight weeks is the average time. In some cases 
cicatrization may be perfect at the end of two or three weeks, 
while in others the same number of months must elapse. 

The technique given varies in some particulars from that 
advocated by other operators. In the division of the incudo- 
stapedial articulation the ordinary direction is to enter the 
knife behind the long arm of the incus and divide the articu- 
lation by cutting downward and forward. Those who advo- 
cate this plan of procedure say that the pressure of the instru- 
ment is then opposed by the action of the stapedius muscle, 
and danger of injury to the stapes is avoided, while at the 
same time the resistance of the stapedius renders the division 
more easy. My own preference is to sever completely the 
stapedius tendon before attempting to disarticulate, as by this 
means the articulation is brought more perfectly into view 
through the action of the tensor tympani and tense ligament- 
ous bands located anteriorly. If the stapedius muscle is not 
completely divided as the initial step, the stapes, after disarti- 
culation, is frequently pulled out of sight behind the margin of 
the tympanic ring. After division of the stapedius, disarticu- 
lation by the method usually recommended may dislocate the 
stapes, although this is not likely to occur. It is often diffi- 
cult, however, to insert the knife between the tympanic ring 
and the long arm of the incus, and for this reason I prefer the 
method given in my description of the technique of the pro- 
cedure — that is, to pass the angular knife in front of the long 
arm of the incus and open the articulation by cutting down- 
ward and backward against the pull of the tensor tympani, or 
to open the joint at its lower aspect, and then to sweep the 
knife through it by carrying it backward and forward. By 
either of these methods the joint is more easily opened than 
when an attempt is made to carry the angular blade behind 
the long process of the incus, which frequently lies so close to 
the tympanic margin that considerable violence must be used 
in introducing the knife. 

In removing the incus Kretschmann,* who was the first to 
formulate the procedure for removing this ossicle, made use 
of a hook which, in addition to the curve shown in Fig. 123 j ' k, 
was bent outward at the distal extremity so that when the in- 
strument was in position the tip rested upon that small shelf- 

* Arch, fur Ohrenheilk., vol. xxv, p. 165. 



CARIES OF THE INCUS. 507 

like structure of the superior wall of the canal which affords 
lodgment for the incus. He introduced the instrument with 
the concavity directed backward, and brought the incus into 
view by rotation backward and traction downward. While 
this manipulation is no doubt of great value in certain cases, 
the backward rotation seems more likely to carry the ossi- 
cle far out of reach toward the mastoid antrum in case it is 
not secured at once, and the manipulation of attempting to 
bring the long process into view by passing a hook behind it 
and rotating forward has in my hands proved very satisfac- 
tory, while it certainly lessens the danger of displacing the 
ossicle far backward. 

The teaching that it is not advisable to make a prolonged 
search for the incus seems to me unwise. In nonsuppurative 
cases careful manipulation will render failure to secure it ex- 
ceedingly rare. If it has not been displaced it must occupy 
its original position, and failure to bring the long process into 
the field of vision will render it impossible for the operator to 
be certain of a complete division of the incudo-stapedial articu- 
lation ; or if the head of the stapes is seen lying free in the 
field, it is certain that the incus has been displaced and, by 
acting as a foreign body, may give rise to trouble if allowed 
to remain. If the long process is in view there is no difficulty 
in removing the ossicle. 

In purulent cases it is still more important that the ossicle 
should be removed. Ludewig * found the incus carious in 
eighty-five per cent of the cases upon which 
he operated. In twenty-nine cases of puru- <^& ( -^ 
lent otitis operated upon by the author,f the FlG - ho.— Caries of 

. . . ... incus. Long pro- 

ossicle was carious in nineteen, while in eight cess destroyed; 
it had been completely destroyed. Prolonged erS^AuAoS 
manipulation in searching for the ossicle has specimen, natural 
not, in my hands, in any way added to the re- 
action following the procedure, nor has it interfered with the 
results. I should therefore earnestly advise prolonging the 
operation for the purpose of securing the incus rather than 
performing a rapid operation and failing in its removal. 

Among the complications which may interfere with the 
operation, haemorrhage is the one upon which special empha- 



* Arch, fur Ohrenheilk., vol. xxix, p. 241 ; vol. xxx, p. 263. 

f Supplement to the Reference Handbook of Medical Sciences, New York, 1893. 



508 MIDDLE-EAR OPERATIONS. 

sis is laid. Since I have operated with the patient in the semi- 
recumbent position rather than with the head low, annoying- 
haemorrhage has been the exception rather than the rule. If 
it is sufficient in amount to interfere with the manipulation, 
it can always be checked by tamponing the canal firmly with 
cotton pledgets. It is important in executing this. manoeuvre 
that the first pledget of cotton should be carried well into the 
tympanic cavity, and also that the individual pledgets should 
not be too large, as the force necessary for the removal of 
a large tampon is likely to lead to a recurrence of the haemor- 
rhage. This objection is overcome if a number of small plugs 
are used instead of a few larger ones. It may be necessary 
to repeat the tamponing several times, but it will certainly 
effect its purpose if a little patience is exercised. A ten-per- 
cent solution of cocaine is said to be useful in checking a 
slight oozing, but I have never had occasion to use it. 
Schmiegelow * has reported one case in which the haemor- 
rhage was so severe that he was obliged to discontinue an 
attempt to excise the malleus. 

My own experience with intratympanic operations, more 
especially the particular class now under discussion, has led 
me to consider them remarkably free from risk. It is possi- 
ble, however, for unpleasant sequelae to follow such proce- 
dures. Among these the most important are injury to the facial 
nerve, deafness from accidental impaction of the stapes into 
the oval window, injury to the labyrinth from accidental or 
intentional removal of the stapes, either by direct trauma- 
tism or by infection, etc., and inflammation of the mastoid 
process. 

The facial nerve is occasionally injured by the incus hook. 
The cause of this accident is to be found either in a congenital 
defect in the Fallopian canal or in the partial or complete de- 
struction of its walls as the result of disease. With the exer- 
cise of a little care in manipulating the incus hook, bearing in 
mind that great force is not necessary to displace the ossicle, 
the accident can usually be avoided. If the facial nerve is 
touched by the instrument the twitching of the face immedi- 
ately warns the operator of what has occurred, and subse- 
quent caution will prevent serious injury. In one of my own 
cases twitching of the face was noticed while attempting to 



Hospitals Tidende, 3, R. V., Nos. 22-26. 



STACKE'S OPERATION. 509 

locate the incus, and upon recovery from anaesthesia there was 
marked paresis of the corresponding side of the face ; the fa- 
cial nerve had been slightly involved before the operation, but 
after this the signs were much more pronounced. The paraly- 
sis disappeared under the use of the faradic current. Facial 
paralysis consecutive to a similar operation occurred also in a 
case reported by Ludewig.* 

In view of the fact that all portions of the tympanic cavity 
are not accessible through the canal, and in order that the pro- 
cedure may be more directly under the eye of the operator, 
Stacke f prefers to expose the parts by external incision. His 
method is as follows : An incision is made down to the bone 
just behind the attachment of the auricle, and, following this 
in direction, is continued from the tip of the mastoid process 
to a point just above the tragus. With a small elevator the 
cartilaginous meatus and as much as possible of the perios- 
teum of the osseous canal are separated from the bony parts. 
In this manner the superior, posterior, and inferior aspects of 
the margin of the bony meatus are exposed. The soft parts 
are now divided transversely downward and forward as 
deeply in the canal as possible, and by traction upon the auri- 
cle the funnel-like mass is pulled out of the bony meatus (Fig. 
150). The periosteum of the anterior wall is next divided, 
when the entire cartilaginous meatus and a part of the thin 
cutaneous lining of the osseous canal may by traction for- 
ward be so displaced as to leave the margin of the bony 
meatus entirely free. The tympanic structures may then be 
seen by direct light and all affected parts removed. By 
means of the gouge the superior and posterior margins of the 
inner extremity of the bony meatus may now be removed, 
and the stapes being protected by a proper instrument, the 
curette may be freely used in the vault of the tympanum, 
the manipulations being under ocular inspection. In this 
manner the entire cavity may be cleared completely of ne- 
crotic tissue and the mastoid antrum even may be exposed. 
In case there is evidence of serious mastoid involvement the 
original incision is made a little farther back than directed and 
the antrum entered in the ordinary way, after which the tym- 
panic cavity is exposed and treated in the manner described, 

* Arch, fur Ohrenheillc., vol. xxix, p. 259. 
f Ibid., vol. xxxi, p. 201. 



5io 



MIDDLE-EAR OPERATIONS. 



and finally the canal and the artificial opening into the antrum 
are thrown into one. In this way the middle ear, mastoid 
cells and canal are converted into a single cavity, all parts of 
which are easily accessible through the external meatus. 

After the operation the cartilaginous canal is replaced and 
a drainage-tube is passed into the bony meatus, completely fill- 
ing its lumen, thus preventing displacement. The external 
incision is sutured, all drainage being through the meatus. In 
cases where the mastoid antrum has been freely exposed it is 
usual to incise the soft parts of the canal longitudinally along 
the posterior aspect and press the flaps thus formed backward 
into the cavity, holding them in position with tampons of iodo- 
form gauze. In this manner a cutaneous lining for the mas- 
toid antrum is secured. The same result is attained by cut- 
ting a quadrilateral flap from the cutaneous canal and carrying 
it into the antrum. 

Stapedectomy. — (a) When the membrana tympani is intact. 
The incudo-stapedial articulation is exposed either by a curved 
incision in the postero-superior quadrant close to the attach- 
ment of the membrane to the tympanic ring, or by a triangu- 
lar incision in this situation, or by the incision already de- 
scribed in the operation of exploratory myringotomy. After 
the incudo-stapedial articulation is brought into view the sta- 
pedius muscle should be completely divided ; the incudo-sta- 
pedial articulation is then severed and the long arm of the 
incus pushed forward so as not to interfere with the subse- 
quent steps. If the presence of the incus still interferes with 
the separation of the stapes the long process may be seized 
with the forceps and the ossicle removed. The stapes is then 
freed, by means of the sharp straight knife, from adhesions 
binding it to the oval niche, and is removed by gentle traction 
with the forceps or by a hook passed between the crura. It is 
important to sever the stapedius muscle completely before dis- 
articulation, as otherwise, after separation from the incus, the 
stapes may be pulled out of view. If the foot plate is found 
anchylosed this condition may be treated in the manner al- 
ready suggested, although in such a case, as the parts would 
be subjected to more violence, it is probable that removal of 
the malleus, incus, and membrana tympani would diminish 
the chances of reaction after the operation. 

After the first incision through the membrana tympani, 
the direct application of the cocaine solution to the middle 



REMOVAL OF THE STAPES. 5II 

ear by means of a cotton-tipped probe renders the subse- 
quent steps painless. In three cases of this kind I have been 
able to clear the oval niche in the above manner, no pain 
being- experienced after the first incision through the mem- 
brana. If a very sharp knife is used this is never severe. 
After this no pain need be felt if cocaine is carefully applied. 
My results have been fairly satisfactory ; but I am inclined at 
present to confine the procedure to cases where the condi- 
tion has resulted from a suppurative inflammation, and in non- 
suppurative cases to mobilize the stapes instead of removing 
it. In these cases, if mobilization improves the hearing, I 
also prefer to remove the malleus and incus, thus leaving the 
stapes accessible in case a second mobilization becomes ne- 
cessary. 

After removal of the stapes the flap may be replaced and 
held in position by a paper dressing. The meatus is occluded 
by a plug of antiseptic cotton, which is left in position for 
several days unless inflammatory symptoms supervene. The 
wound usually heals in a few days, and in no case has the re- 
action been severe. 

(b) WJien tJie membrane is partially destroyed the stapes or 
the incudo-stapedial articulation may be already in view ; but 
if neither is visible, the appropriate incision for the expo- 
sure of these parts will vary in each case, after which the 
technique previously given is to be carried out. In two cases 
operated upon under local anaesthesia, the stapes being clearly 
in view, extraction was easily accomplished and the results 
were flattering, in one instance the hearing for a low whisper 
increasing from seven to thirty feet. Here the entire stapes 
was removed intact. In the second case only a portion of 
the ossicle was secured and removed, yet the improvement 
was considerable. It is well to bear in mind that even slight 
haemorrhage will render the removal of the stapes difficult ; 
and when this region is covered by dense structures, which 
bleed freely when incised, it may be necessary to remove the 
malleus and incus and remains of the membrane to secure a 
suitable field for the performance of stapedectomy. 

The after-treatment may be the same as in the preceding 
class of cases. It is well, however, to inspect the ear at the 
end of twenty-four hours, and, if signs of inflammation are 
present, to cleanse it frequently with a mild antiseptic solu- 
tion. If, however, the parts are perfectly dry, they should 



c I2 MIDDLE-EAR OPERATIONS. 

not be disturbed, for fear of interfering with the healing- 
process. 

From personal experience, the author believes that at the 
present time a lesion of the conducting mechanism resulting 
from a nonsuppurative inflammation which demands opera- 
tive interference will be more satisfactorily combated by the 
removal of the membrana tympani, malleus, and incus, and mo- 
bilization of the stapes, than by other operative measures. In 
residual purulent cases mobilization of the stapes will usually 
yield results equally as good as those obtained by stapedec- 
tomy. The advantage of removing the two larger ossicles in 
both classes of cases lies in the fact that the stapes is thus left 
exposed, and can be repeatedly mobilized if necessary. When 
the ossicle is mobilized or removed, and the flap of drum mem- 
brane is allowed to resume its former position, the beneficial 
results are often but temporary, and disappear when the 
opening in the membrana closes. 

When operations are performed for improvement of func- 
tion they may always be conducted under local anaesthesia, 
and the improvement or failure to improve may be noted at 
each successive step. The operation can therefore be discon- 
tinued at any stage, if the operator judges that he is not war- 
ranted in proceeding. 

The results of my operations were reported * a few 
months since, and the compilation which follows includes a 
few additional cases. 

Of cases where the membrana tympani was intact, includ- 
ing one or two instances where there had been a suppurative 
process in childhood, w T ith complete closure of the perfora- 
tion, twenty-one have been subjected to operation under co- 
caine anaesthesia. Of these, there was much improvement in 
thirteen cases, with a slight relapse in one case ; there was a 
moderate amount of improvement in seven, with a relapse in 
one instance ; and in one case — a female of neurotic tempera- 
ment — the improvement was but slight. 

In thirteen cases of this character operated upon under 
ether, two were greatly improved, five much improved, five 
slightly improved, and in the remaining case the condition 
remained the same as before operation. 

In eleven cases the condition was due to a previous purulent 

* Transactions of the American Otological Society, 1894. 



STATISTICS OF AUTHOR'S OPERATIONS. 



513 



inflammation, which had resulted either in a slight or extensive 
destruction of the membrana tympani, the perforation persist- 
ing. The operative procedures were confined to freeing the 
stapes and mobilizing it., as described in the preceding pages, 
without resort to general anaesthesia. Of these, there was 
great improvement in one, the whispering distance increasing 
from twelve inches before to fifteen feet after operation, and 
the degree of improvement being maintained at the time of the 
last examination, which was about six weeks after operation. 
In ten there was decided improvement, although not as great 
as in the case just mentioned. Of the eleven cases, disagree- 
able symptoms followed the operation in but one instance. 

In ten cases there was a purulent otitis, in which the opera- 
tion was performed both for the relief of the otorrhcea and at 
the same time to improve the hearing. Of these, there was 
great improvement in five, moderate improvement in three, 
while in two the function of the organ remained the same as 
before operation. 

In ten cases the membrana was intact and the stapes was 
removed, or the crura fractured in the attempt at removal, 
the operation being done with cocaine. In most instances 
removal of the incus was necessary in order to gain access to 
the stapes. Of the ten cases, three were improved, two were 
much improved, one slightly improved, two unimproved, and 
two were made worse. In one case, where much improve- 
ment followed the operation, a relapse took place at a later 
period, although the hearing still remained better than before 
the operation. 

In quite a number of these cases of stapedectomy it was 
found that the improvement became much less after the per- 
foration in the membrana tympani closed, and in these in- 
stances the malleus and membrana tympani were removed at 
a later period, in order to secure a permanent opening into 
the tympanic cavity. This procedure was followed by im- 
provement in all the cases. In one instance synechiotomy 
was practiced for the improvement of hearing before the 
purulent discharge had ceased entirely, this being so moder- 
ate in amount as scarcely to warrant general anaesthesia and 
the removal of the entire ossicular chain. Slight improve- 
ment followed the procedure in this instance. 

It will be seen from these statistics that the greatest im- 
provement has followed those operations performed under 



5H 



MIDDLE-EAR OPERATIONS. 



cocaine anaesthesia, and where the design has been to secure 
a permanent opening into the tympanum. This seems to be 
the most rational procedure in all cases where the membrana 
tympani is intact ; and since it can be done without general 
anaesthesia, we are certainly warranted in recommending at 
least an exploratory tympanotomy in all cases where the hear- 
ing has failed to improve under less radical measures. In no 
given case can we state the amount of improvement which we 
should expect, and it is always our duty to inform the patient 
of the experimental character of the measure. From the fact, 
however, that the procedure is followed by no discomfort, 
that it can be performed without pain, and that, humanly 
speaking, it will not injure the organ, we certainly fail to ful- 
fill our entire duty to the patients if the subject is not pre- 
sented to them fairly. 



PLATE VI 




The Mastoid Operation. 



CHAPTER XXVIII. 

THE MASTOID OPERATION. 

The instruments required are a medium-sized scalpel (Fig. 
141), thumb forceps (Fig. 142), scissors (Fig. 143), retractors, 
either sharp or blunt (Fig. 144), a periosteum elevator (Figs. 
145, 146), a rongeur forceps (Fig. 147), sharp spoons (Figs. 
123, a, and 148), a silver probe, a wooden or rawhide mallet, 
and chisels or gouges of various sizes (Fig. 149). It is also 
well to have a small trephine at hand. The usual supply of 
artery clamps (not less than six), needles, and silk and catgut 
sutures will naturally form a part of the armamentarium. 

The ear should be first thoroughly cleansed by syringing 
with i-to-1,000 bichloride solution, or with a dilute (1 to 10) 
solution of peroxide of hydrogen, after which the meatus is 



Fig. 141. — Scalpel for incising the soft parts in the mastoid operation. The handle 
is of metal, and the extremity is useful in elevating the periosteum. 

thoroughly tamponed with iodoform gauze. The scalp should 
be shaved over an area extending in every direction for a dis- 
tance of three inches from the meatus, and if the patient has a 
beard it should also be removed. The skin is then scrubbed, 
first with soap and water and then with ether, and finally 
with a solution of bichloride of mercury (1 to 1,000), or a two- 
and-a-half-per-cent solution of carbolic acid. A wet bichloride 
dressing is then applied over the entire field of operation and 
allowed to remain until the patient is anaesthetized. When 
possible, this preparation of the field should be made at least 
four or five hours before the time of operation. 

After the induction of anaesthesia the antiseptic dressing 
is removed, the tampon within the canal is changed, and the 
integument washed again with ether, and irrigated subse- 
quently with a bichloride solution (1 to 2,000). The parts 
immediately surrounding the field should be covered with 

(515) 



5 i6 



THE MASTOID OPERATION. 



towels moistened in i-to-i,ooo bichloride solution. All instru- 
ments are to be sterilized by boiling, and the hands of the 
operator and his assistants should receive the ordinary atten- 
tion demanded in all surgical operations. 

It may seem unnecessary to take all these precautions in a 
procedure apparently so simple ; but when we remember 
that, owing to an anomalous position of the parts, or to the 
destruction resulting from the inflammation, we may either 




fT 



Fig. 142. — Thumb 
forceps. 



Fig. 143. — Blunt scis- 
sors for separating 
sterno-mastoid mus- 
cle from tip of mas- 
toid. 



Fig. 144. — Sharp 
retractor. 



enter the cranial cavity accidentally or feel 
compelled to do so as a matter of election, 
w T e should never undertake the procedure 
without being thoroughly prepared to extend 
our operation in this direction if necessary. 
The primary incision begins over the middle Fig. 145— Perios- 
of the mastoid insertion of the sterno-cleido- 
mastoid muscle, about half an inch below the tip of the mas- 
toid process, and is carried upward and forward close to 
the line of insertion of the auricle, after which it follows 
this line to a point directly above the meatus (see Plate 
VII). Particular attention should be given to the location 



DIVISION OF SOFT PARTS. 



517 



of this incision, as ordinarily the line of section lies so far back 
that when the flaps are retracted the posterior and superior 
walls of the canal are not freely exposed. In addition to this, 
the free vascular supply of the 
anterior flap causes it to be- 
come cedematous almost im- 
mediately, thus increasing the 
difficulty with which it is drawn 
forward, rendering a perfect 
exposure of the parts impossi- 
ble. If the line of incision is 
made so close to the auricular 
insertion as to admit of the in- 
troduction of a line of sutures 
only, the field of operation will 
be much better exposed, while 
subsequent deformity will be 
prevented, the cicatrix being 
concealed completely by the Fig. 146.— Hart- 
auricle, which resumes an abso- ^devat^ 




Fig. 147. — Rongeur 
forceps. 



lutely normal position. The 
soft parts should be divided to the bone throughout the 
entire extent of the incision. If bleeding is free, the larger 
vessels may be grasped with clamps, although it is better or- 
dinarily to delay this until the periosteum has been elevated. 
This constitutes the next step of the operation : The entire 
anterior flap is pushed forward by means of an elevator car- 
ried beneath the periosteum, raising this and the overlying 
muscular structures from the bone, the parts being pushed 



Fig. 148. — Sharp spoon. 

forward until the posterior and superior margins of the bony 
canal are plainly in view. The posterior flap is elevated in a 
similar manner. All bleeding points are now caught by means 
of clamps. The auricle is held forward by a narrow retractor 
inserted into the meatus, the instrument being intrusted to the 
hands of the assistant. The upper part of the incision is filled 
with sponges, in order that all oozing may be controlled, while 
the operator directs his attention to clearing the aponeurosis 
of the sterno-mastoid muscle from the tip of the process. 



5i? 



THE MASTOID OPERATION. 



a 



Fig. 149. — Sdiwartze's mastoid chisels. 



This is best done with blunt scissors curved on the flat, 
which can be closely applied to the bony surface and made 
to divide the dense fibrous tissue by successive short cuts. 
Care must be taken to hug the bone closely, otherwise the 
large vessels of the neck may be injured. This separation of 
the muscle should be continued until the finger can be passed 
completely around the tip of the mastoid, and if the primary 
incision has not been made low enough to allow this, it must 
be extended. The packing is now removed from the upper 
part of the wound and the exposed area is examined for 
the presence of any sinus, the result of spontaneous rup- 
ture. If this is found, it is enlarged either by the curette or 
gouge, the surgeon following the channel which has been 

thus established, and 
which will be found 
in all cases to com- 
municate either di- 
rectly or indirectly 
with the mastoid an- 
trum. If no sinus 
is present, the first 
step in ever)- case is 
to enter the antrum. 
We remember the 
location of this to be 
just behind the pos- 
terior margin of the 
meatus and just be- 
low its superior mar- 
gin. Until we have 
gained entrance to 
this cavity our open- 
ing through the cortex should never extend above the supe- 
rior wall of the canal, thus avoiding the middle cranial fossa, 
while we should keep close to the posterior wall on account 
of a possible malposition of the lateral sinus. 

The cortex is best removed by means of the chisel (Fig. 
149) and mallet, a large cutting instrument being used at 
first and changed for a smaller one as the wound is deep- 
ened. The chisel is applied nearly parallel to the surface of 
the skull, and made to cut away the bone in thin, broad 
chips, the cutting edge being directed downward and for- 




REMOVAL OF SOFTENED BONE. 5IQ 

ward. In this way we form a bony funnel, the base of which 
may be broadened posteriorly and below, if necessary, but 
never above. The apex of the cone should always lie within 
the triangle which marks the entrance to the antrum. Where 
the pneumatic spaces are superficial they may be opened 
with the first blow of the mallet, after which it is wise to 
lay aside the chisel and continue the operation by means of 
the sharp spoon (Fig. 148), breaking down the walls of the 
air spaces until the mastoid antrum is entered. This never 
lies less than half an inch below the surface, although we 
may encounter large pneumatic spaces more superficially. 
We recognize that the antrum is entered by the fact that a 
probe, slightly curved at the tip, after entering the artificial 
opening, passes downward, forward, and inward for a dis- 
tance of from three quarters to seven eighths of an inch, at 
which depth it enters a cavity of considerable size ; in other 
words, it has passed into the middle ear. We persist in our 
efforts at entering this cavity, although pus may have been 
evacuated previously. The passage between the antrum and 
the tympanum should next be curetted freely by means of a 
delicate sharp spoon (Fig. 123, a). This portion of the tract 
is invariably occluded by granulation tissue, while its bony 
walls are often carious. 

The next step is to thoroughly obliterate the entire pneu- 
matic structure of the mastoid process. The remaining cortex 
is removed with the chisel, curette, or rongeur, as may be 
most convenient. The large cell at the apex must be particu- 
larly investigated, opened freely, and, if its walls are carious, 
the tip of the process should be removed with the rongeur 
forceps. The operation should be continued until sound 
bone is encountered in every direction. If the inner table is 
affected, we should not hesitate to remove it, as an exposure 
of the dura under proper precautions is a matter of no impor- 
tance, while to leave carious bone in contact with this, is a 
grave error. Exposure of the lateral sinus, either accident- 
ally or intentionally, in no way complicates the operation. If 
the vessel is opened, sharp haemorrhage results, and herein 
lies the advantage of extensively removing the cortex. If the 
wounded vessel lies at the bottom of a deep, narrow, bony 
channel, the haemorrhage may be controlled ; but it is diffi- 
cult to proceed with the. operation, and the purpose for which 
it was instituted will therefore not be carried out. With a free 



520 



THE MASTOID OPERATION. 



removal of the cortex the bleeding point lies plainly in view, 
and the haemorrhage is easily controlled by a firm compress 
of iodoform gauze. This is held by an assistant, and the sur- 
geon finishes the operation as though nothing untoward had 
happened. Haemorrhage from the sinus is no more severe 
than that from one of the large venous trunks of the upper 
extremity, and the possible untoward results which may fol- 
low a wound of this vessel will depend upon the imperfect 
exposure of the bleeding point rather than upon the loss of 
blood or the accidental infection through the sinus. 

Having now removed all softened bone, the wound may 
or may not be irrigated, according to the individual choice 
of the surgeon. I am inclined to favor dry cleansing. The 
bony cavity is packed loosely with iodoform gauze, the tam- 
pon in the canal is reapplied, and the soft parts are allowed 
to fall back over the opening in the bone, their edges being 
separated by a narrow strip of gauze only. It is not neces- 
sary to pack the external wound, as was formerly done, and 
the omission certainly renders the first dressing more com- 
fortable. Any points which bleed upon removal of the pres- 
sure forceps may be tied, but this is seldom necessary. The 
dressing is completed by covering both the wound and the 
ear with several layers of dry sterilized gauze and cotton, the 
whole being confined in place by a bandage. 

In cases where the technique has been perfect it is not 
necessary to remove the dressing under five or six days. The 
necessity of changing the dressing at an earlier period will 
be indicated by a rise in temperature or by local pain. 
Where the temperature does not exceed ioi° at any time 
during the first five days, or, if elevated, is not persistent, 
the dressing need not be changed. 

The subsequent treatment is simple. At the first dressing 
we frequently find the canal absolutely free from discharge. 
Unless the discharge is profuse, v either from the canal or from 
the wound, irrigation is not to be employed at the subsequent 
dressings. If considerable secretion is present it is wise to 
irrigate the parts freely, the fluid employed being introduced 
through the artificial opening and allowed to pass out of the 
meatus ; the technique of the dressing is the same as at the 
time of operation. Where the lateral sinus has been opened, 
or the dura exposed in any other location, particular care is 
necessary at each dressing to guard against local infection, 



ACCIDENTS DURING OPERATION. 5 2i 

the exposed dural area being- uncovered first, cleansed and 
protected with a gauze pad, after which the packing may be 
removed from the mastoid portion of the wound and the 
dressing done as above directed. 

In addition to wounding the sinus, the operator may oc- 
casionally expose or even wound the dura in the middle 
cranial fossa. Entering the cranial cavity at this point can 
be avoided in every instance if the cortex is not removed 
above the level of the superior wall of the canal. When the 
temporal ridge is very prominent and the margin of the 
meatus is placed so far below this as to render adherence to 
this rule almost impossible, the operator may deem it wise to 
extend the opening in the bone slightly above the line indi- 
cated. If the calvarium is unusually thin, even the most 
careful operator may enter the cranial cavity. It will seldom 
happen that the dura is wounded if care is taken to remove 
the bone in successive thin lamellae, and its exposure does no 
harm. It is only necessary to disinfect the parts by means of 
a warm i-to-5,000 bichloride solution, or with a sponge moist- 
ened in the same fluid, after which the opening is covered by a 
pad of gauze ; this is intrusted to an assistant, and the opera- 
tion completed in the ordinary manner. Where the dura is 
wounded, the opening in the bone should be enlarged ; and if 
the membrane has been perforated, it may be wise to enlarge 
this opening so as to thoroughly cleanse the underlying 
parts. After this the dural opening is closed with a fine gut 
suture and treated in the manner above described. With a 
careful operator such an accident is absolutely harmless, and 
in no way complicates the progress of the case. In the ma- 
jority of instances a prominent temporal ridge means either a 
sinus situated farther forward than normal, or a low middle 
cranial fossa, and the surgeon will be particularly careful to 
confine himself to the limits of safety when these anatomical 
features present. 

Since the squamous plate of the temporal bone is more 
horizontal in infancy than in adult life, and the manner in 
which the fibrous canal is applied to the outer surface of the 
squama on account of the absence of the bony canal at birth, 
attention should be given to certain variations which must 
be practiced when the mastoid of a very young child is to 
be operated upon. At birth, since the fibro-cartilaginous 
meatus along its superior aspect is applied to the external 

35 



522 



THE MASTOID OPERATION. 



surface of the squama, the line of attachment of the auricle 
to the skull lies at a much higher level than does the mem- 
brana tympani, and the superior extremity of an incision 
along: the line of auricular attachment would lie at a much 
higher level than the upper border of the tympanic ring 
(Fig. 122). The relative position of the parts at the line of 
auricular attachment is misleading, since, when the anterior 
flap is pulled forward, the fibrocartilaginous tube constitut- 
ing the meatus is attached so firmly above and behind as to 
frequently mislead the operator and cause him to think that 
the margin of the annulus has been exposed. If the bone is 
perforated without exposing the posterior limb of the annulus 
clearly, and making out the exact situation of the prominent 
posterior tubercle, both by touch and by inspection, the 
operator may accidentally open the middle cranial fossa in- 
stead of the pneumatic space of the mastoid and middle ear. 
The superior and posterior attachments of the meatus should 
be separated carefully from the squama after the primary 
incision until the posterior tympanic tubercle is reached 
and the canal merges into the drum membrane. It is often 
well to incise the fibrous tube transversely for a short distance, 
in order that a clear view may be obtained of the membrana 
tympani and render an error impossible. If the bony cavity 
is entered just behind this tubercle and close to it, the antrum 
will be opened, after which it will be easy to chip away the 
external table for a considerable distance forward and up- 
ward, thus exposing the tympanic vault (Fig. 122). It is wise, 
however, to make it a rule to never remove the outer layer of 
bone at a higher level than the posterior tympanic tubercle as 
a primary procedure. The depth of the middle cranial fossa 
varies considerably in different subjects, but always lies above 
the point named. The exact conformation of the parts in any 
individual case is easily made out when access is once gained 
to the pneumatic spaces, after which the operator will adapt 
his operation to the anatomical conditions present. The 
external wall of the tympanic vault at birth occupies in real- 
ity the position of its inferior wall in adult life, owing to the 
change in direction taken by the squamous plate as develop- 
ment progresses. The vault will therefore be entered with 
very little trouble close above the line of attachment of the 
membrana superiorly. Another word of caution is also 
proper regarding the initial incision. Since the mastoid 



POSSIBLE DIFFICULTIES. 523 

squamous suture is not ossified at birth, and frequently pre 
sents large dehiscences filled by fibro-cartilage, the knife, in 
making the initial incision, should not be pressed with any 
force upon the bone, but the soft parts should be divided 
slowly until the bone is exposed throughout the line of in- 
cision. Firm pressure upon the scalpel might easily result in 
plunging it into one of these dehiscences, causing it to enter 
the cranial cavity. The utmost gentleness should also be ob- 
served in dissecting up the periosteum and turning the ante- 
rior flap forward, for the same reason. 

In every instance, then, either in adults or in children, no 
procedure should be instituted for the removal of osseous 
tissue until the posterior and superior margins of the bony 
canal are not only accessible to the ringer but plainly in view, 
and the soft parts should be so retracted that the landmarks 
may be always under the eye of the surgeon throughout the 
entire operation. 

The facial nerve as it crosses the tympanic cavity is occa- 
sionally wounded in cases of sclerosis where the bone has 
been removed to a sufficient depth to expose the internal 
wall of the middle ear. The aquasductus Fallopii lies within 
the middle ear, and consequently it is impossible to wound it 
until the operation is really completed and free communica- 
tion established with the tympanum. It is wise, after per- 
forating the bone to a depth of seven eighths of an inch, or 
perhaps a little less, to pass a probe bent at a right angle into 
the external auditory meatus, and carry the angular portion 
upward and backward into the tympanic vault, in which posi- 
tion it is to be held. The operator then has only to continue 
the removal of bone until the artificial opening exposes this 
probe within the tympanum. A wound to the external semi- 
circular canal is more unlikely to occur than one of the facial 
nerve. The canal lies immediately above the aqueduct, and 
can only be injured when the opening is made exceedingly 
high. When in any doubt as to the advisability of perforat- 
ing more deeply on account of the possibility of injuring 
either of these structures, the plan usually followed is to re- 
move that portion of the posterior wall of the canal lying 
immediately in front of the artificial opening. The canal 
must lead into the middle ear, and the removal of this bony 
partition until the tympanum is reached renders the comple- 
tion of the procedure absolutely safe. In these cases that 



524 



THE MASTOID OPERATION. 



portion of the bony posterior wall at the inner extremity of 
the canal, made up of compact osseous tissue, should be left, 
since it is possible to wound the facial nerve under these con- 
ditions if the entire posterior wall is removed. Injury to the 
facial nerve is not a serious accident, function being restored 
in from three to five weeks, in most cases, under the use of 
the faradic current. 

In cases of cholesteatoma the operation is modified to this 
extent, that the partition between the meatus and the artificial 
opening in the mastoid is always removed. The technique 
of the operation consists in opening the mastoid antrum and 
obliterating the walls of the cells in the manner already de- 
scribed. The upper extremity of the cutaneous incision is 
then extended slightly downward to a point just above the 
tragus, while below it is curved forward beneath the lobule to 
a point immediately below the antitragus. With the perios- 
teum elevator the fibro-cartilaginous canal and the periosteum 
of the bony meatus are carefully separated from their osseous 

attachments. The posterior 
wall is then divided trans- 
versely, by means of a knife, 
as close to the membrana 
tympani as possible, and by 
traction upon the auricle 
the membranous funnel-like 
flap, composed of the pinna 
and the attached meatus, is 
drawn outward as a whole, 
thus exposing to direct in- 
spection the bony canal, and, 
if the drum membrane is de- 
stroyed, the tympanic cavity 
and its contents. Where the 
ossicles are carious, these 
are removed, after which 
the partition between the 
mastoid opening and the me- 
atus is broken down, and 
the margin of the tympanic ring, above and posteriorly, chis- 
eled away, until the probe, bent at a right angle and car- 
ried upward into the tympanum, meets no obstruction at the 
margin of the ring when withdrawn from the canal. To ren- 




Fig. 150. — The tympanic vault and its con- 
tents exposed by the removal of its outer 
wall, and the division of the fibrous me- 
atus transversely close to the membrana 
tympani. (Author's specimen, natural 
size.) 



BERGMANN'S OPERATION. 



525 



der the healing more rapid, the fibrocartilaginous portion of 
the meatus which has been drawn forward is now split along 
its posterior aspect by a horizontal incision extending from 
its point of detachment close to the membrana tympani to 
the root of the auricle, thus forming two triangular flaps, 
which may be pressed backward into the large bony cavity 
remaining after the operation. These flaps are held in posi- 
tion by a tampon inserted into the canal, and by adhering to 
the denuded bone facilitate the rapid development of a cu- 
taneous lining to the cavity. The soft parts posteriorly are 
then sutured, in order that better approximation may be ef- 
fected, all drainage taking place through the meatus. It is 
wise to introduce a moderate-sized drainage tube into the 
canal as far as the membrana tympani, to prevent deformity 
of the meatus, which might easily occur from a slight dis- 
placement of the outer segment. This tube may be removed 
at the first dressing, and need not be replaced. After the sec- 
ond day a tampon will support the parts sufficiently. 

In cases where the mastoid cells and the vault of the tym- 
panum have become involved in an inflammatory process,, 
and drainage through the external auditory meatus is insuffi- 
cient, Bergmann has advised a procedure for the evacuation 
of the retained pus and the removal of carious bone. The 
anatomical conditions rendering this possible are found in 
the peculiar method in which the temporal bone develops. 
It will be remembered that during development the squa- 
mous portion in the region of the tympanic cavity sepa- 
rates into two lamellae, the inner forming a portion of the 
tympanic roof, while the other, extending in the direction 
downward and somewhat inward, fills up the gap between 
the free extremities of the tympanic ring, thus completing 
the curved outline superiorly. We also recall that during 
the successive periods of childhood and adolescent life the 
growth of the squama progresses in such a manner that the 
roof of the canal extends outward in almost a horizontal 
direction, so that the structure which in the child consists 
merely of a bony arch, in the adult has been transformed 
into a horizontal bony lamella. The outer wall of the tym- 
panic vault lies at the angle formed by the divergence of the 
internal and external lamellae of the squama. It is evident, 
therefore, that if an artificial opening is made parallel to the 
roof of the canal between these two lamellae it will enter 



526 THE MASTOID OPERATION. 

the vault of the tympanum. Bergmann exposes the supero- 
posterior margins of the meatus by an incision close to the at- 
tachment to the auricle, and separates the fibro-cartilaginous 
canal together with the periosteum of the osseous meatus 
along its superior and posterior aspects, thus exposing the 
superior margin of the bony canal. By means of a chisel the 
superior wall of the meatus and the diploe beneath are care- 
fully chiseled away, following the upper wall of the meatus 
inward until the vault of the tympanum is entered. By this 
procedure direct access is gained to that portion of the cavity 
lodging the malleo-incudal articulation (Fig. 150), a region 
which is especially prone to be the seat of caries in chronic sup- 
puration of the middle ear. Through this opening the ossicles 
can be removed, the tympanic roof curetted thoroughly, and 
all softened bone removed, in a similar manner, from the other 
aspects of the vault. By enlarging the opening posteriorly, 
free access is gained to the mastoid antrum and the other 
mastoid cells. By dividing the posterior and superior wall of 
the fibrous canal in such a manner that the soft parts may be 
crowded into the bony cavity thus thrown into the canal, the 
operator succeeds in placing that series of pneumatic spaces 
which are in communication with the tympanic cavity under 
direct ocular inspection from the meatus, so that any subse- 
quent caries can easily be dealt with without recourse to a 
serious operation. Combined with the operation proposed 
by Stacke, already described, Bergmann's method forms a 
valuable means of securing free drainage, and of removing 
all carious tissue from the deeper portions of the ear. It is 
also valuable in those cases where the lateral sinus lies so far 
forward as to prevent entering the mastoid antrum at the site 
of election. 

The technique of dressing the wound is the same as that 
described under the consideration of Stacke's operation, and 
must vary slightly with each individual case according to the 
indications. 



PLATE VIII 




Exploration of the Tympanic Roof, Lateral Sinus, and Cerebellum. 



CHAPTER XXIX. 

THE SURGICAL TREATMENT OF THE INTRACRANIAL 
COMPLICATIONS OF AURAL SUPPURATION. 

When it has been decided that the intracranial structures 
are involved either subsequently to an operation on the mas- 
toid or when the case first comes under observation, it is wise 
to institute surgical measures for the relief of the condition. 
It has been argued that, from the great mortality following 
such measures, they are not justifiable ; but when we remem- 
ber that the only chance of relief lies in surgical interference, 
it seems wrong to refuse the patient this opportunity. 

In purulent meningitis surgical interference offers less 
promise than in epidural or cerebral abscess, or in sinus 
thrombosis, when prompt action on the part of the surgeon 
often saves life. It is only when unmistakable symptoms of 
extensive meningitis occur that we should hesitate in per- 
forming an operation in any of these cases. 

It is well, in undertaking an operation for the relief of an 
intracranial lesion following a middle-ear inflammation, to re- 
member the advantage of having the opening in the soft parts 
sufficiently ample to permit of extending the opening in the 
skull in various directions, if desirable, without enlarging the 
cutaneous incision. 

The operator may wish to explore the middle fossa, the 
sinus, and the cerebellum at the same operation, and to expose 
each of these areas, as a separate procedure would entail the 
expenditure of much valuable time. It is wise, therefore, to 
expose the bony surface over an area which includes the vari- 
ous sites of election for entering the cavity (Fig. 151). The 
author has found that the exposure is best effected by the 
displacement of a semicircular flap, as shown in Plate VIII. 
This flap is formed by extending the incision, made at the 
time of the mastoid operation, forward along the zygoma for 
a distance of half an inch. From this point an incision is made 
backward to the occipital protuberance. This incision is 

(527) 



528 SURGICAL TREATMENT OF AURAL SUPPURATION. 

slightly curved, the convexity being directed upward; from 
the occipital protuberance the incision is carried vertically 
downward to the level of the tip of the mastoid. If the soft 
parts are now dissected up, a large flap can be turned down 
upon the neck, exposing the surface of the cranium. The flap 
is supplied by the vessels which enter from below, and the 




Fig. 151. — Lateral aspect of skull showing the relative position between the super- 
ficial landmarks and the contents of the cranial cavity, x, x\ Reed's base line. 
This is a horizontal line drawn through the middle of the external meatus and 
the lower border of the orbit. /, Tentorium ; c, Situation of trephine opening 
for exposure of temporo-sphenoidal lobe ; b, Situation of trephine opening for 
examining the roof of the tympanum ; a, Site for opening mastoid antrum ; d, 
Site of election for exposing the lateral sinus ; e, Site of election for opening 
cerebellar abscess. (For convenience the base line is divided into eighths of an 
inch. Modified from Starr.) 



danger of sloughing is avoided. All attached muscles are 
divided longitudinally, and hence their action is in no way 
destroyed. 

In dissecting up this flap, the periosteum is not detached ; 
this is undisturbed, except where the bony wall is removed to 
effect an entrance to the cranial cavity. 

A. Sinus Thrombosis. — Where the mastoid has been previ- 
ously opened, the simplest means of exposing the lateral sinus 
is to enlarge the original opening backward and downward, 
and expose the dura. This opening may be continued back- 
ward as far as the occipito-temporal suture, and the opening 



SINUS THROMBOSIS— EPIDURAL ABSCESS. 529 

thus made will in every case be of ample size to admit of suf- 
ficient access to the sinus for diagnostic or therapeutic pur- 
poses. This opening also enables an exploration of the cere- 
bral and cerebellar fossae. If no previous operation has been 
performed upon the mastoid process, it will usually be wise to 
clear out the mastoid as the primary step of the procedure. 
If we wish, however, to expose the sinus alone, this may be 
done by removing a button of the bone with the trephine, the 
centre pin of the instrument being located at a point seven 
eighths of an inch behind the centre of the bony meatus and 
a quarter of an inch above the horizontal plane through this 
point (Fig. 151, d); the opening may be enlarged with the 
rongeur, if necessary. After the venous channel has been ex- 
posed, the presence of a clot is determined either by the sense 
of touch or by the insertion of a previously sterilized hypo- 
dermic needle. If an infectious thrombus is present, foul- 
smelling pus or decomposed blood is withdrawn, while, if the 
channel is normal, fluid blood alone enters the syringe. 

To remove an infectious thrombus, the w r all of the sinus is 
to be freely incised and its cavity freed of the decomposed clot 
by the delicate use of the curette. It is wise to continue this 
cleansing process until rather free haemorrhage follows. The 
cavity is now packed with iodoform gauze. Where the clot 
has extended downward into the internal jugular vein, as evi- 
denced by tenderness along the anterior border of the sterno- 
mastoid muscle and the presence of a tense, cordlike structure 
occupying the situation of the jugular vein, it is not sufficient 
to disinfect the sinus alone, but the clot from the jugular must 
also be removed, to prevent further systemic infection. To do 
this, it is necessary to expose the internal jugular in the neck. 
It is then divided between two ligatures, after which the su- 
perior portion, containing the thrombus, is removed in exactly 
the same manner as that in the lateral sinus. Any large trib- 
utary vein exposed during the operation must be tied before 
the jugular is divided. The infected area is thus completely 
cut off from the general circulation, and this plan of treatment, 
when instituted early enough, is certainly efficient. If compli- 
cated, as only too often happens, by a collection of pus deep 
in the cerebral substance, or by the presence of a diffuse puru- 
lent meningitis, death will follow in spite of the removal of the 
source of systemic infection. 

B. Epidural Abscess. — For the relief of pus between the 
36 



530 SURGICAL TREATMENT OF AURAL SUPPURATION. 

dura mater and the osseous wall of the cranium it is only 
necessary to perforate the skull in order to evacuate the fluid. 
The decision as to the exact location of such an abscess must 
always be largely a matter of conjecture, and it is well to 
remember that, out of a series of cases reported, the most 
usual location has been either in the posterior or in the middle 
cranial fossa in the order named. The operative technique 
consists in the removal of the inner table of the skull, over 
the site of the mastoid opening, extending- it as much as is 
necessary to expose the dura in the posterior fossa. A probe 
is then inserted between the meninges and bone and passed 
gently in every direction, to discover, if possible, the location 
of the purulent focus. Failing in this, the middle cranial fossa 
should be explored ; this may be done by enlarging the origi- 
nal opening by means of the rongeur. Owing to the thick- 
ness of the skull in this region, it is wiser to perforate a second 
time than to extend the previous opening. For this purpose 
the cutaneous incision is carried first upward, and then for- 
ward and downward to the zygoma. By means of the elevator 
the soft parts are raised from the bone and the trephine ap- 
plied at a point one inch above the centre of the external 
canal (Fig. 151, b); the perforation may be made by means of 
the gouge or chisel, instead of the trephine, if the operator 
prefers. This admits of exploration of the entire tympanic 
roof, and the probe may be carried along the anterior surface 
of the petrous portion of the temporal bone from its base to 
its apex. In many cases the finger may be used for the pur- 
pose of exploration. The exposure of the middle cranial fossa 
by removal of the tympanic roof seems to me more difficult 
than by the manner above described, and the space gained is 
certainly much less. Pus being encountered, it is only neces- 
sary to thoroughly wash out the cavity and secure drainage 
by the insertion of strips of gauze, the external wound being 
allowed to heal by granulation. If we have been fortunate 
enough to locate the abscess, these cases usually terminate 
favorably ; all untoward symptoms disappear upon evacua- 
tion of the fluid, and prompt recovery follows. 

C. Cerebral Abscess. — There may be localizing symptoms 
sufficiently definite to point to the exact site of the lesion ; 
when this is the case, the cranial cavity is entered over the 
proper area either by means of the trephine or chisel. In 
case the situation is believed to be near the mastoid opening, 



CEREBRAL ABSCESS. 53I 

it is only necessary to enlarge the previous wound. Only too 
frequently we are in the dark as to the exact situation of the 
purulent collection, and the operation is exploratory in char- 
acter, the diagnosis depending rather upon the absence of 
definite symptoms than upon the presence of those indicative 
of the involvement of any one particular region. 

The area best adapted to exploration of the cranial cavity 
is one the centre of which lies an inch and a quarter behind 
the centre of the canal and an inch and a quarter above its 
horizontal plane (Fig. 151, c). Through a free opening here 
we are able to explore the temporo-sphenoidal lobe, the pos- 
terior cerebral lobe, and the entire neighboring epidural 
space as well. From this point as a centre, the opening 
may be extended either forward or backward, as may seem 
desirable during the progress of the operation, and access 
gained to almost every part of the cavity of the cranium. 
This central point should be marked upon the skull before the 
integument is raised ; this is done by piercing the soft parts 
with a stout scalpel or by a small drill, so as to leave a mark 
upon the bony surface recognizable after reflection of the 
soft parts. The area should be exposed by reflecting the 
semilunar flap downward, as before described. The point 
for the application of the trephine will lie at about the centre 
of the exposed area. The trephine may be of large size, to 
permit of the parts being explored in every direction for a 
considerable distance, and to allow free manipulation of the 
divided structures ; or, as I prefer, a small trephine may be 
used, and the opening enlarged with the rongeur. After 
exposing the dura and finding no extradural collection, a 
dural flap is to be raised and the probe passed in every direc- 
tion between the dura and the surface of the brain. Care 
should be taken to locate the line of incision through the dura 
so as to avoid any large venous trunks, as haemorrhage from 
these will complicate the operation considerably. If we have 
no indication of the exact situation of the abscess, a large aspi- 
rating needle, properly disinfected and attached to a good- 
sized hypodermic syringe, may be thrust into the brain sub- 
stance in various directions for the purpose of exploration. 
In general, these punctures should be made first downward, 
forward, and inward, the piston of the syringe being drawn 
up as soon as the needle enters the brain tissue, and the point 
of the instrument advanced slowly, so that any thin-walled 



532 



SURGICAL TREATMENT OF AURAL SUPPURATION. 



abscess may not be overlooked. In the same manner we re- 
peat this step by passing the needle directly inward, forward 
and inward, and downward, backward and inward. The 
traumatism sustained by the brain tissue from these punctures 
seems to be of but little importance. 

If one of the lateral ventricles is entered, the syringe fills 
with ventricular fluid, and, as in all intracranial diseases 
attended with venous hyperasmia, the ventricular fluid is 
increased in amount ; the withdrawal of this fluid is certainly 
of therapeutic value. We should also remember that a cere- 
bral abscess may rupture into the ventricles, and then these 
cavities must be opened and drained in order to secure the 
desired end. 

For exploration of the cerebellum, the opening through 
the skull should be located an inch and a half behind the 
centre of the meatus and a quarter of an inch below its hori- 
zontal plane (Fig. 151, e). The technique is the same here as 
when the cranial cavity is opened in other situations. The 
value of the aspirating needle as an instrument of exploration 
has perhaps been overrated. The pus found in these ab- 
scesses is frequently so thick that it will not pass through 
the needle even if it be one of large size ; and after the menin- 
geal flap has been raised it is quite as wise to use a simple 
grooved exploring needle, as the instrument suggested above. 
If pus is found, the brain substance itself is incised freely with 
the probe-pointed bistoury, the contents of the abscess evacu- 
ated, and a gauze drain inserted. 

If the dura has been incised extensively, this opening may 
be partially closed by means of fine silk sutures. The intra- 
cranial pressure is increased, no matter what the exact char- 
acter of the lesion may be, and difficulty may be experienced 
in preventing a hernia cerebri, the cerebral matter protrud- 
ing so much through the opening in the skull as to render 
suture of the dural flap somewhat difficult. An evacuation 
of the ventricular fluid relieves the tension sufficiently to 
permit an apposition of the edges of the divided dura. The 
pericranium is replaced, and either not sutured at all or at 
the angles of the wound simply. The wound is then dressed 
in the ordinary manner. 

D. Purulent Meningitis. — In instituting operative proce- 
dures for a purulent meningitis, the rational symptoms seldom 
aid us in deciding the area involved. The first step, there- 



PURULENT MENINGITIS. 533 

fore, should be to thoroughly open the mastoid and tympanic 
vault, and, if the site of perforation into the cranium is dis- 
covered, the cavity is to be entered by enlarging- this open- 
ing. II no sinus is found, or if there is no localized area of 
caries which suggests the site of the meningeal inflammation, 
the tympanic roof should be explored by entering the cranial 
cavity above the meatus. If no evidence of meningitis is 
found here, the inner table should be removed in the area of 
the mastoid wound, and the opening enlarged by the rongeur 
or chisel until the sinus is exposed. The anterior margin of 
the sinus will be encountered about half an inch behind the 
posterior margin of the meatus, as a rule. Any focus of in- 
flammation is to be thoroughly cleansed by means of a warm 
solution of bichloride of mercury (i to 3,000), after which the 
surface is to be covered with iodoform gauze. The outer 
wound is packed in the same manner, and the parts covered 
with a dressing of bichloride or sterilized gauze. 



SECTION IV. 

DISEASES OF THE PERCEPTIVE MECHANISM. 

(535) 



DISEASES OF 
THE PERCEPTIVE MECHANISM. 



The sound-perceiving apparatus includes the medullary 
nuclei of the auditory nerve, and the nerve fibres joining 
these to the cortical areas in the first and second temporal 
convolutions. Passing from the medullary centres in the oppo- 
site direction, it includes the trunk of the auditory nerve and 
its terminal filaments specialized in the labyrinth for sound 
perception. 

In addition to the perception of sound, the auditory nerve 
trunk contains a distinct group of fibres which preside over 
the equilibrium of the body. The terminal filaments of these 
fibres are distributed to the semicircular canals, while their 
cortical areas within the cranium are found within the cere- 
bellum. Interference with the perceptive mechanism is con- 
sequently attended in most instances by some disturbance of 
equilibrium. This may be so slight as to entirely escape the 
notice of the patient unless his attention is particularly drawn 
to it, or it may be the principal disorder for which he seeks 
relief. Interference either with equilibrium or with the func- 
tion of audition, characterized by an impairment in this func- 
tion or its perversion, may depend upon organic changes in 
any portion of the mechanism specialized for this particular 
purpose. It may be also of reflex origin, no structural change 
having taken place in any portion of the ear, but an affection 
of some remote organ influencing by reflex action this par- 
ticular part of the economy. 

It follows, therefore, that the history of the individual is 
of particular importance in connection with diseases of this 
portion of the auditory apparatus. Some illness in early life, 
or a slight traumatism, might entirely escape the mind of the 
patient, as having no bearing upon the condition for which he 
seeks advice, but may often lead us to a correct interpretation 

(537) 



538 DISEASES OF THE PERCEPTIVE MECHANISM. 

of the cause of a symptom. The physical examination of the 
ear is really a very small part of the investigation in these 
cases, and one who confines himself to this special examina- 
tion alone must invariably fall into error in his attempts to cor- 
rectly explain the cause of many of the symptoms. Certain 
phenomena are characteristic of involvement of this portion 
of the organ of hearing. The hearing power, in cases where 
the perceptive mechanism is principally involved, is either 
profoundly affected or but slightly changed, the moderate 
grades of impairment depending usually upon diseases of the 
conducting apparatus. Tinnitus is almost always present, 
and, if carefully investigated, we shall usually find a history 
of attacks of vertigo. I am of the opinion that sufficient stress 
is never laid upon the symptoms dependent on labyrinthine 
involvement in the ordinary cases of diseases of the conduct- 
ing apparatus. A secondary labyrinthine disturbance may 
occur as a complication or as a sequel of changes within the 
middle ear, and yet of itself require no treatment other than 
that directed to the tympanum. This latter fact does not 
make it less a labyrinthine affection, the removal of the cause 
being the rational method for overcoming this disturbance. 

With reference to the impairment of hearing, low-pitched 
sounds are perceived better than those of high pitch, particu- 
larly if a preceding disease of the middle ear has led to the 
involvement of the nervous apparatus. Marked variations 
in the degree of impairment, dependent upon climatic changes 
or mental or physical fatigue, are quite as characteristic of a 
pathological condition located here as they are of middle-ear 
changes. 

Where the power of audition changes with the weather, 
being worse on damp days and improving as the atmosphere 
clears, it is usually supposed that the disturbance depends 
upon a middle-ear affection. If we remember the intimate 
relation between the venous circulation within the turbinated 
bodies and the venous return current from the cochlea, we 
can easily understand how a turgescence of the nasal mucous 
membrane will cause a venous stasis within the labyrinth. 
No better proof can be afforded that this is the case than the 
marked relief to subjective noises often observed when the 
turbinated tissues are exsanguinated by the use of cocaine. 

The duration of the affection and its progress also aid us 
in determining its site. Primary lesions of the perceptive 



GENERAL OBSERVATIONS. 



539 



apparatus either remain quiescent or improve to a certain 
extent spontaneously as time progresses, excepting, of course, 
those dependent upon a specific inflammation. Secondary 
changes within the receptive apparatus, organic in character, 
are usually due to some chronic affection of the middle ear 
either of the same or opposite side. When the opposite or- 
gan is primarily affected the impairment of function advances 
rapidly, as a rule, and here the history of previous tympanic 
disease renders diagnosis clear. The character of the subjec- 
tive noises is of aid in locating the lesion, in that the particu- 
lar character of the sound points to the special part of the 
labyrinth involved. Almost invariably in the secondary laby- 
rinthine changes due to chronic suppurative or nonsuppura- 
tive otitis media the subjective noises are high-pitched in char- 
acter, and assume a deeper quality only after they have per- 
sisted for a long period. The complete cessation of tinnitus 
in these secondary cases probably indicates that the laby- 
rinthine invasion has ceased to progress, and the length of 
time during which the patient has been free from subjective 
noises is of aid in determining the probability of restoring 
the parts to their normal condition by treatment. Vertigo, if 
severe, points to a sudden and considerable disturbance with- 
in the perceptive mechanism, as at the onset of an attack, or 
to an aggravation of an existing condition. Repeated attacks 
of giddiness of a mild character would indicate that at these 
periods the labyrinthine structures or the higher centres 
were subjected to some unusual stimulation either from the 
tympanum, from intracranial changes, or of a reflex character 
from some visceral derangement. The effect of continued 
stimulation of the nervous mechanism by sonorous vibrations 
— as when the patient is subjected to the noise of a railway 
train for a number of hours, or has taxed himself to the ut- 
most in listening to conversation which it has been difficult 
for him to hear — is of value in diagnosis. Prolonged excita- 
tion of any nerve, at length renders it less susceptible to the 
particular stimulus which has fatigued it. When the nerve 
structures are in an abnormal condition they become fatigued 
more easily than when in a state of health ; and a patient will 
often be found to be more deaf after a prolonged railway jour- 
ney than when he has been comparatively quiet. Physical 
fatigue may indirectly bring about the same result. It is 
sometimes said that the paracusis Willisii is characteristic of 



5 4 DISEASES OF THE PERCEPTIVE MECHANISM. 

involvement of the nervous apparatus. This may be true 
when the patient is subjected to a noise for a short time ; but 
if the stimulation is continued, the nerve becomes fatigued 
and less responsive to stimuli. The reverse takes place when 
the nerves preserve their integrity and the conducting mech- 
anism is at fault. 

The determination of the special part of the perceptive 
mechanism involved must remain a matter of doubt in a cer- 
tain proportion of cases. In general, it may be said that the 
history of a previous middle-ear affection, of an acute infec- 
tious disease, or of a traumatism with a slight impairment of 
hearing, points to an involvement of the labyrinth. On the 
other hand, where we have symptoms referable to the ear 
in cases giving a history of severe injury followed by an 
involvement of the intracranial structures, as evidenced by 
other symptoms, or where there are other manifestations of 
cerebral disturbance at the time of the examination — such as 
local paralysis, psychic phenomena, etc. — we should suppose 
that the auditory cortical centres had suffered. An affection 
of the trunk of the nerve should be suspected when the im- 
pairment is to an extent uniform, or affects particularly the 
perception of those sounds to which the ear is most frequently 
subjected, since, when all the fibres of the trunk are involved, 
the fibres which are most constantly used will be most seri- 
ously affected. Marked variations in sound perception de- 
pendent upon excitement, fatigue, disturbance of the prima 
vise, etc., would characterize the aural affection as reflex. 
Bearing these various points in mind, Ave should always se- 
cure the general history in every case of aural disease, so as 
to obtain data which will yield the desired information. 



CHAPTER XXX. 

ANAEMIA OF THE LABYRINTH. 

Etiology. — The condition may depend upon profuse gen- 
eral haemorrhage, either from traumatism, from the rupture 
of an aneurism, from uterine haemorrhage at childbirth, or 
may be the result of simple or pernicious anaemia. The 
changes which take place are due to the impoverished qual- 
ity of the blood with which the tissues are supplied, the lack 
of nutrition perverting their function and rendering them 
less capable of carrying out the purposes for which they 
were designed. 

Symptomatology. — When the labyrinthine structures. suffer 
in this manner we find the power of audition impaired, par- 
ticularly for sharp sounds and musical notes of a high pitch. 
The involvement of the auditory function is similar in char- 
acter to the disturbance which is noticed in every part of 
the body. When nutrition is imperfect no organ performs 
its work properly. When the labyrinth suffers from mal- 
nutrition the patient seems listless and inattentive, and it 
requires a certain effort upon his part to hear what is said. 
When engaged in dialogue the hearing may not seem to be 
much affected, but when several are speaking at once he is 
unable to follow accurately the course of the conversation. 
Subjective noises are distressing, and are usually worse upon 
lying down, depending upon the adynamic condition of the 
circulatory system. The character of the subjective sounds 
is usually dull and low-pitched, synchronous with cardiac 
pulsations, and is apparently identical with the venous bruit 
heard over the great vessels of the neck in many cases of 
anaemia. Attacks of vertigo seldom occur spontaneously, but 
result from apparently slight causes, a sudden fright being 
sufficient many times to induce an attack of syncope, while 
the same condition may follow an insignificant degree of pain 
or some slight visceral disturbance. The facies of the patient 
is somewhat characteristic, in that it appears dull, abstracted, 

(541) 



542 ANEMIA OF THE LABYRINTH. 

and inattentive. The other symptoms presented are those 
common to simple anaemia, and bear no relation to the por- 
tion of the body now under discussion. 

Diagnosis. — The pallor of the skin found after an acute 
haemorrhage, or the peculiar ashy-gray color met with in 
cases of simple or pernicious anaemia, should always attract 
attention. The variation in color from the normal standard 
is frequently better observed in the mucous membranes than 
in the cutaneous surface of the body. These may appear 
blanched, although the face is not sufficiently pallid to excite 
attention. 

A. Physical Examination. — In cases of simple anaemia, ex- 
amination with the otoscope reveals nothing characteristic of 
the affection, and, unless the middle ear is involved, the in- 
spection is entirely negative. 

B. Functional Examination. — The lower tone limit is nor- 
mal ; the upper tone limit may be normal or reduced ; bone 
conduction is almost always reduced to a marked degree. 
The perception of whispered or spoken words is somewhat 
reduced, although it may be nearly normal. It will be no- 
ticed that the words are repeated in an uncertain manner and 
slowly, as though it took the patient some time to compre- 
hend exactly what had been said. This is due to inco-ordina- 
tion in the receptive mechanism, the different portions failing 
to act in harmony. Perception for high sounds, as the tick 
of the watch or the click of the acoumeter, is usually more 
reduced relatively than for vocal sounds. 

The essential points upon which the diagnosis is made are : 

First, the absence of any middle-ear lesion. 

Second, preservation of the normal tone limits (or reduc- 
tion of upper limit). 

Third, marked impairment of bone conduction. 

Fourth, the anaemic appearance of the patient. 

Prognosis. — In acute cases depending upon haemorrhage, 
or in cases of simple anaemia, the prognosis is always favor- 
able. In pernicious anaemia, extravasations within the nerve 
tissues may have taken place, producing permanent structural 
changes. 

Treatment. — Certain drugs, such as iron in full doses, or 
arsenic, either in the form of arsenious acid, Fowler's solution 
or Pierson's solution, etc., should be administered for the pur- 
pose of improving the quality of the blood. The exhibition 



TREATMENT. 



543 



of cardiac stimulants is also advisable to relieve the venous 
congestion within the labyrinth. Strychnine fulfills this end, 
and at the same time exerts a beneficial effect upon the nerv- 
ous tissues themselves. This may be given simultaneously 
with ferruginous preparations, and should be administered in 
full doses. The diet should be liberal, and of such character 
as to improve the quality of the blood. The exhibition of 
alcohol in any quantity is not advisable, excepting in acute 
cases, or possibly to the extent of a little red wine at dinner. 
Quinine is particularly contraindicated in this condition. It 
is true, that many cases improve temporarily when this drug 
is administered ; but it is equally true that they almost invari- 
ably suffer from a relapse, and that the symptoms are more 
marked than those which characterized the primary attack. 
The temporary engorgement which this drug induces in the 
labyrinthine vessels often leads to permanent changes of a 
hemorrhagic nature. The temporary relief gained is due to 
the increased vascularity which the drug causes, and not to 
correction of the condition upon which the symptoms depend. 



CHAPTER XXXI. 

HYPEREMIA OF THE LABYRINTH. 

Etiology. — An increased quantity of blood within the 
labyrinth may depend either upon a venous stasis from me- 
chanical obstruction to the return current, or upon an in- 
creased quantity of arterial blood conveyed to the part. The 
condition is prone to occur in individuals of a full habit, and 
particularly in those who are the victims of a gouty or rheu- 
matic diathesis. Those whose vocation in life demands con- 
siderable physical activity or exposure to inclement weather 
are frequently victims of this condition. Sudden physical ex- 
ertion is productive of these circulatory changes, especially in 
athletes. Overindulgence in alcohol, by increasing the force of 
cardiac systole, leads to distention of the labyrinthine vessels. 
Rigidity in the arterial system, by diminishing the elasticity 
of the vessels, increases relatively the pressure within the ar- 
teries. Sudden diminution in atmospheric pressure, as when 
one ascends to a great height, subjects the efferent vessels to 
the full force of the cardiac systole, and hence augments the 
blood passing through them. The prolonged action of any 
one sound also produces hyperasmia, either mechanically or 
from over-stimulation, as is observed in telephone operatives, 
boiler-makers, etc. Condensation of the air in the meatus, 
from a blow on the ear or from an explosion, forces the 
stapes suddenly inward to an abnormal distance, and may 
cause hyperasmia of the labyrinth. It is probable that cases 
of mild labyrinthine concussion are of this nature. 

Among those causes which lead to a venous stasis we may 
enumerate mechanical obstruction to the great vessels of the 
neck, such as pressure from a tumor or the sudden lowering 
of the head, the venous flow being then retarded by the force 
of gravitation. A severe attack of coughing, by increasing 
the pressure within the thorax, temporarily obstructs the pas- 
sage of the blood into the right auricle and dams back the 

(544) 



PATHOLOGY— SYMPTOMATOLOGY. 545 

entire venous circulation. Efforts at sneezing, blowing the 
nose, etc., exert the same influence. 

Pathology. — The overdistention of the blood vessels pro- 
duces but few changes so long as their walls are in a state of 
perfect health ; when continued for a long time, localized dila- 
tation takes place, causing an irregularity in the blood supply. 
Where the pressure changes are sudden, or where the walls 
of the vessels are diseased, they may rupture and produce 
apoplectic changes. A venous hypersemia is more prone to 
become permanent on account of the tenuity of the vessel 
walls. The labyrinthine veins are to a great extent inclosed 
in bony channels, for the purpose of avoiding this condition. 
Their exposed portions, however, suffer when an obstruction 
to the venous circulation persists for a considerable period ; 
the vessels become tortuous and dilated, and there is a transu- 
dation of serum into the labyrinthine cavity. Both the venous 
dilatation and the serous transudation increase labyrinthine 
pressure. The ultimate changes which take place in laby- 
rinthine apoplexy do not differ from those occurring in a 
similar condition in other parts of the body. The effused 
blood may be absorbed, or the affected area may undergo 
disintegration. 

Symptomatology. — Such an augmentation in labyrinthine 
blood supply is characterized by a feeling of fullness and dis- 
tention in the head, slight giddiness or even vertigo, and the 
presence of subjective noises, usually of high-pitched char- 
acter. The impairment in hearing is slight, unless the vessel 
walls suffer ; then it may be profound or even absolute, the 
accompanying giddiness being usually severe, and the tinnitus 
at first almost unbearable. Occurring as a chronic condition 
in a patient of full habit, we find these symptoms produced 
by any slight exciting cause, such as fright, rage, sudden ex- 
ertion, indigestion, too free indulgence in stimulants, etc. 

Diagnosis. — Physical examination yields no information be- 
yond showing an increased vascularity in the drum mem- 
brane and the deeper parts of the canal, causing the vessels 
to be more distinctly visible than normal. Where the raem- 
brana tympani is thin, a similar condition is often observed in 
the mucous membrane of the promontory. 

Functional Examination. — The lower tone limit is exceed- 
ingly well preserved ; the upper tone limit is usually reduced ; 
bone conduction is diminished, and the power of audition for 

37 



546 HYPEREMIA OF THE LABYRINTH. 

vocal sounds but slightly impaired. For sharp sounds, such 
as those of the acoumeter or watch, a condition of hyperacu- 
sis may be present, and very sharp sounds are often painful ; 
or the auditory impression may persist for some time after 
the source of sound has been removed. The diagnosis in 
chronic cases will be rendered more easy if attention is di- 
rected to the increased vascularity of the integument of the 
face and the prominence of the smaller vessels beneath the 
skin, which is a fair index of the condition of the circulatory 
system within the labyrinth. The history of severe physical 
exertion or of a gouty or rheumatic diathesis also materially 
aid us in arriving at a correct opinion. 

Prognosis. — Where .but slight impairment of hearing is 
present, we may hope, in recent cases, to effect an absorption 
of the effused serum and a return of the parts to a condition 
of integrity. Where the condition is of long standing, the 
outlook is more unfavorable, and the same is true where the 
changes are of hsemorrhagic nature, if the extravasation is of 
considerable size. In chronic cases it is seldom possible to 
remove the condition entirely, although much relief may be 
secured by carefully regulating the habits of life. 

Treatment. — In severe cases local depletion is a most im- 
portant measure to be adopted. Considerable blood should 
be abstracted from the mastoid region by means of the wet 
cup. General bloodletting is permissible when the attack is 
of unusual severity. Free catharsis should be effected by the 
administration of saline purgatives, and free diuresis should 
also be obtained. In acute cases it is well to protect the 
ear from the action of sound by occluding the meatus with 
cotton. The application of counterirritants to the mastoid 
in the form of blisters is advocated by some, but is of more 
value where the condition has continued for some time than 
immediately after an exacerbation. The use of counterirri- 
tation for a long period by means of the tincture of iodine 
applied to the mastoid region is of some value in the older 
cases, since the effusion of serum within the labyrinthine 
chamber implies an increase in pressure. The use of pilo- 
carpine is of benefit, and we should always resort to it if 
prompt relief does not follow the abstraction of blood. In 
administering this drug, it is convenient to employ a four- 
per-cent solution, as in this way the dose can be gradually 
increased according to indications. The initial dose for an 



TREATMENT. 547 

adult is from one sixth to one eighth of a grain twice or three 
times daily. It is not necessary to confine the patients to the 
house to the extent of interfering with their daily vocations in 
carrying out the treatment. It is only necessary that for about 
two hours after each dose the patient should guard against 
draughts. This is secured if one dose of the drug is taken 
immediately upon rising in the morning, when the effect will 
have passed sufficiently before the patient is obliged to go out 
to his daily work, while the second may be taken upon re- 
tiring. The quantity administered should be just sufficient 
to increase the salivary or cutaneous secretions slightly, but 
a profound effect is undesirable. The patient should be di- 
rected to increase the dose, so that the physiological action 
is noticed after each ingestion, as otherwise tolerance is soon 
established and the full benefit to be derived is not obtained. 
It is also of great value in instances which come under treat- 
ment only after a considerable interval has elapsed since an 
acute attack, the reduction in pressure frequently being fol- 
lowed by relief. This is probably due to the absorption of 
the effusion. Iodide of potassium internally, in doses of ten 
grains three or four times daily, may be given for the same 
purpose, but is usually less efficacious. Next to the treatment 
of an acute attack, the most important measures are those of 
a prophylactic nature. Severe and sudden physical exertion 
should be enjoined. Alcohol should be interdicted, and the 
diet should be so regulated as to diminish the general pleth- 
ora. The influence of a gouty or rheumatic taint should 
never be forgotten, and the prolonged use of some alkaline 
waters, preferably those containing lithium, is of great value. 
Attention to these matters not only tends to relieve the 
chronic congestion, but also renders the patient less liable to 
an apoplectiform lesion. 



CHAPTER XXXII. 

LABYRINTHINE HEMORRHAGE. 

Etiology. — The cause of a rupture of the walls of the 
labyrinthine vessels, with an extravasation of their contents 
into the delicate structures which the cavity contains, may be 
due to external violence, such as a blow upon the head or a 
fall from a height, or the sudden action of a loud sound, such 
as an explosion. It may be caused by manipulative proce- 
dures directed toward the relief of some middle-ear condition, 
as a forcible inflation by means of the catheter or Politzer 
bag, or severe efforts at coughing or sneezing. Mobilization 
or removal of the stapes may also produce the condition 
under discussion. 

Various conditions of the blood itself — such as that found 
in the hemorrhagic diathesis, in pernicious anaemia, and in 
leucaemia, or fragility of the walls of the blood vessels met 
with in patients of advanced years, especially those who are 
victims of a gouty diathesis — may determine the same result. 
The same accident may take place from sudden venous con- 
gestion of the head, as produced when one remains with the 
head bent forward for a considerable time, or when the ve- 
nous blood is prevented from entering the right auricle by 
holding the breath, as in swimming under water or in diving. 
Necessarily the condition may be met with as a complicating 
lesion of cerebral hyperasmia. 

Pathology. — The effusion of blood into the tissues pro- 
duces the same changes here as a similar lesion in other 
parts of the body. Where the haemorrhage is considerable, 
complete disorganization of the parts may take place from 
pressure, and a return to the normal condition becomes im- 
possible even if the effused blood is subsequently absorbed. 
In other cases the traumatism is not so great, and the struc- 
tures pressed upon simply suffer from a mechanical interfer- 
ence with the performance of their function without under- 

(548) 



SYMPTOMATOLOGY— DIAGNOSIS. 



549 



going degeneration ; this is always produced by increased 
labyrinthine pressure, when the equilibrium is restored only 
after a considerable period. The clot itself may remain and 
become organized, or may be completely absorbed or undergo 
fibrous or calcareous degeneration. According to the amount 
of original damage, the function of the part is either entirely 
destroyed or partially or completely restored. 

Symptomatology. — When a labyrinthine apoplexy occurs, 
the patient is usually seized with giddiness so severe as to 
cause him to fall unless he obtains some artificial support ; at 
the same time there is intense nausea, severe tinnitus, and a 
very high degree of impairment of hearing, or absolute deaf- 
ness. Unconsciousness may occur if the attack is severe. 
When it follows chronic labyrinthine hypersemia, certain pre- 
monitory signs often manifest themselves, such as a feeling of 
fullness and distention in the head, a throbbing within the 
ears, the cardiac impulses being not only heard, but appar- 
ently felt deep in the head. The unsteadiness of gait and 
impairment of hearing usually disappear after a few days or 
weeks, the former completely, and the latter to a marked 
degree, although the hearing does not become normal. The 
subjective noises persist, and may even increase in severity. 
Occasionally a condition of hypersesthesia of the auditory 
nerve follows, certain sounds being painful, although the gen- 
eral auditory power is greatly impaired. An attack of this 
kind renders it probable that subsequent attacks may occur, 
especially when it is due to a pathological condition of the 
walls of the blood vessels. 

Diagnosis. — The suddenness of the attack, the severity of 
the vertigo and of the tinnitus, the extreme nausea, and the 
sudden and marked impairment in hearing form a series of 
symptoms which are fairly characteristic. A physical exami- 
nation reveals no departure from the normal standard. 

Functional examination, in addition to the impairment of 
hearing, both for spoken words and sharp sounds, will show 
an impairment or absence of sound perception through the 
solid media of the skull. The limits of audition may be vari- 
ously affected, according to the particular site of the lesion. 
Generally the lower portion of the labyrinth is involved, in 
which case the lower tone limit remains normal, while the 
upper tone limit is lowered to a very marked degree. This 
is not absolute, for if the haemorrhage occurs in the upper 



550 LABYRINTHINE HEMORRHAGE. 

part of the cochlea high notes may be the only ones heard, 
while the low notes are not perceived at all. 

Prognosis. — When the haemorrhage involves but a very 
small area, spontaneous recovery may take place. When the 
lesion is extensive it is probable that the hearing will remain 
to a degree impaired whether the case be left to itself or sub- 
jected to medication. Improvement may be hoped for in the 
more severe cases rather than in those where the extravasa- 
tion is moderate. The prognosis as to the disappearance of 
subjective noises is less favorable, and complete relief should 
never be promised. The disturbance of the equilibrium usu- 
ally disappears completely. 

Treatment. — When seen immediately after the attack, local 
depletion and even general bloodletting are the first measures 
to be instituted. A wet cup to the mastoid exerts more influ- 
ence upon the circulation within the labyrinth than when ap- 
plied in any other location. Free purgation should then be 
effected, absolute rest in bed enjoined, and the patient should 
be protected, as far as possible, from loud noises, and forbid- 
den to do any manual work. At a later period the adminis- 
tration of pilocarpine, beginning with a dose of one sixth of 
a grain three times daily and increasing rapidly until the 
physiological effect is obtained, often causes rapid improve- 
ment by reducing labyrinthine pressure. The general condi- 
tion should be attended to in the same manner as directed 
under labyrinthine hyperasmia. Iodide of potassium, con- 
tinued for six or eight weeks, seems to favor the absorption 
of the clot. Counter-irritation over the mastoid process by 
means of iodine or vesicants is a measure to be employed if 
convalescence is delayed. Great care should be taken to warn 
the patient of the danger of a similar attack at some future 
time. 



CHAPTER XXXIII. 

LABYRINTHINE EMBOLISM AND THROMBOSIS. 

^Etiology. — The lodgment in one of the smaller vessels of 
the internal ear of an infectious embolus which may have 
been thrown into the circulation as the result of a patho- 
logical change in some distant organ, or the development of 
infectious thrombi within the venous channels, are both con- 
ditions met with in rare instances. Embolism is specially 
rare, although it has occurred in cases of osteomyelitis, and 
has been produced artificially in the lower animals by the 
injection of some of the low vegetable organisms into the 
blood. A thrombosis occurs more frequently as the result of 
a severe suppurative process within the middle ear, such as 
is found in scarlatina, diphtheria, etc. Here the blood supply 
of the external labyrinthine wall is greatly interfered with, 
and infection takes place by contiguity of structure through 
the osseous partition. This form of occlusion of the venous 
channels constitutes the labyrinthine lesion in many cases 
which suffer from severe purulent otitis during one of the 
exanthemata. 

Pathology. — The occlusion of an arterial twig produces at 
first an anaemia of the area which it supplies ; this may go on 
to disintegration if the blood supply is not re-established, but 
if the collateral circulation is free this may not occur. Throm- 
bosis of a venous trunk is of less importance except where it 
is due to an acute infectious process, when the minute septic 
foci may break down and produce severe inflammation of the 
surrounding parts. 

Symptomatology. — The symptoms, in general, resemble 
those of labyrinthine haemorrhage, except that they are less 
severe ; nausea is rare ; vertigo may be scarcely noticeable, 
and the hearing power but slightly impaired. The sudden 
development of tinnitus in these cases is probably the most 
constant symptom. It is probable that in many instances 
where tinnitus alone is complained of, the hearing power 

(551) 



552 LABYRINTHINE EMBOLISM AND THROMBOSIS. 

being normal, according to the most careful tests, a small 
artery or vein within the labyrinth has become occluded, 
causing sufficient structural change to produce this symptom 
without otherwise impairing the function of the organ to a 
noticeable extent. From the intimate relation between the 
venous current within the turbinated bodies and that of the 
cochlea, we might suppose that a suppurative inflammation of 
one of the accessory sinuses, such as the ethmoid, antrum, or 
frontal sinus, would be particularly prone to produce this 
effect. It is certainly true that many of these cases suffer 
from subjective noises, while the history shows that the onset 
was sudden, that the noise has remained unchanged for a con- 
siderable number of years, or has perhaps slightly diminished, 
while any impairment of hearing that existed in the early stage 
of the affection has disappeared. Here the inference, that 
embolism of one of the minute vessels has been the lesion 
which has produced the symptom, seems logical. 

Prognosis. — Extensive destruction of the labyrinthine 
structures frequently follows a severe suppurative inflam- 
mation within the tympanum. When confined to a small 
area the condition usually improves as age advances, and 
although it sometimes disappears spontaneously, it is often 
unaffected by treatment. The lesion does not tend to pro- 
gress, and either remains quiescent or slowly improves. 

Treatment. — The first indication is to remove the cause, 
to prevent a repetition of the accident. Measures directed 
toward the labyrinth itself may be necessary where the affect- 
ed area is extensive. The reduction of labyrinthine pressure 
by the internal administration of pilocarpine and subsequently 
of iodide of potassium is practically the most serviceable plan 
of treating either thrombosis or embolism. For the constant 
tinnitus, the use of dilute hydrobromic acid in full doses will 
be found to be beneficial not only in relieving the symptom, 
but, by reducing the degree of hyperesthesia of the recep- 
tive centres, will often exert a certain curative effect. The 
drug should be given in doses of half a drachm every four 
hours, or more frequently if necessary. It should be well 
diluted with water, to. avoid irritation of the stomach. Strych- 
nine in full doses is also of value in preventing a rapid disor- 
ganization of the nerve tissue supplied by the occluded vessel 
both by its specific effect upon nerve tissue and its action as 
a cardiac stimulant. 



CHAPTER XXXIV. 

SPECIFIC INFLAMMATION OF THE LABYRINTH. 

JEtiology. — This portion of the receptive mechanism may 
be the seat of changes due to hereditary or acquired specific 
disease. In the hereditary cases the association of ulcera- 
tive keratitis is so frequent as to point to the dependence of 
both conditions upon the same cause. When it occurs as the 
result of acquired specific disease, it is usually found in the 
tertiary period, although very rarely it is met with in the 
secondary stage. 

Pathology. — The changes which are found upon post- 
mortem examination are of a chronic inflammatory character. 
The lining membrane of the semicircular canals and cochlea 
is thickened, narrowing the lumen of the channels, and in 
some instances this process has gone on to the development of 
new osseous tissue, causing a thickening of the bony walls of 
the passages. Changes characteristic of specific disease are 
present in the blood vessels ; they consist in an obliterating 
endarteritis, narrowing or completely occluding the vessel 
lumen. From this the parts are supplied with an insufficient 
quantity of blood, and suffer from impaired nutrition, which 
may cause necrosis if sufficiently complete. Where the nutri- 
tion is seriously interfered with the parts may undergo sof- 
tening, in the same manner as occurs in gummata in various 
parts of the body. When there is a hypertrophic process 
within the vestibule the newly formed bone maybe depos- 
ited about the oval window, producing a thickening of the 
foot plate of the stapes or a synostosis of the stapedio-vestibu- 
lar articulation. 

Symptomatology. — The occurrence of sudden and pro- 
found impairment of hearing, with the development of sub- 
jective noises, in an adult apparently in perfect health and 
with no evidences of middle-ear involvement, should always 
excite suspicion of an underlying specific cause. In the he- 
reditary cases the impairment in hearing may be steadily 

(553) 



554 SPECIFIC INFLAMMATION OF THE LABYRINTH. 

progressive, and associated with ulceration of the cornea, as 
before mentioned. In children this combination of symptoms 
is particularly liable to occur, and, unless checked by treat- 
ment, progresses rapidly, so that the hearing power becomes 
almost completely lost in a short time. Disturbances of equi- 
librium are not common, and when present are usually slight. 
The association of middle-ear symptoms may be confusing, 
and mask for a time the true cause of the attack. 

Diagnosis. — The diagnosis depends upon the suddenness 
of the onset and the profound degree of impairment in hear- 
ing, while vomiting and severe vertigo are absent. 

If physical examination reveals the middle ear normal, the 
diagnosis is rendered much more simple ; when occurring in 
the secondary stage, an associated tubal or tubo-tym panic in- 
flammation may be so marked as to lead the observer to sup- 
pose that the symptoms are entirely due to the condition of 
the middle ear, and the labyrinthine lesion may be overlooked 
entirely. Functional examination, however, ordinarily pre- 
vents this error. The low notes are fairly well heard even if 
the middle ear is involved, the lower tone limit not being 
elevated proportionately to the degree of impairment of hear- 
ing. The upper tone limit is very much lowered, and sharp 
sounds are poorly perceived, the impairment in this direction 
being more marked than the impairment for conversation. 
Bone conduction is greatly reduced or entirely absent, thus 
rendering the error of attributing symptoms to an affection 
of the middle ear almost impossible. Other signs of specific 
disease should also be sought for. In children, an examination 
of the teeth often reveals characteristic " Hutchinson teeth," 
while the surface of the body may present evidences of a pre- 
vious specific eruption. The examination of the skin is of 
particular importance in adults where the disease is acquired 
rather than hereditary. The association of ulceration of the 
cornea should also be regarded with suspicion. 

Prognosis. — The difficulty in determining the value of any 
form of medication in these cases depends upon the fact that 
the disease may remain quiescent for a long period, and sud- 
denly be excited to renewed activity by some intercurrent 
disease, or from no assignable cause. 

We therefore can not always say whether the cessation of 
the symptoms occurs spontaneously or is the result of treat- 
ment. Medication is of value in recent cases without ques- 



TREATMENT. 



555 



tion, but in those of hereditary origin many believe that the 
disease can not be checked by therapeutic measures. In spite 
of this, no case should be considered as hopeless without hav- 
ing- been first subjected to a thorough course of specific 
treatment. 

Treatment. — In no class of labyrinthine cases is treatment 
more gratifying than in those depending upon acquired spe- 
cific disease. Cases due to a hereditary taint respond less 
promptly to treatment, and many go so far as to assert that 
improvement never follows the exhibition of drugs. In this 
latter class of cases my experience is so limited that I do not 
feel warranted in giving a personal opinion on the subject. 
In the acquired cases, however, even after a considerable 
time has elapsed since the aural symptoms were first noticed, 
internal medication has been followed by gratifying results. 
The internal administration of pilocarpine, beginning with 
doses of one sixth of a grain and increasing the dose until the 
physiological effect of the drug is obtained, as fully described 
in a previous chapter, is almost invariably followed by im- 
provement, both as regards the subjective noises and the 
hearing. Its action is much more marked if, in connection 
with it, we exhibit the iodide of potassium in full doses, begin- 
ning with ten grains three times daily, and increasing it to 
two or four drachms daily. In addition — or at intervals, 
during which the iodide is discontinued — small doses of the 
bichloride of mercury (one thirty-second to one sixteenth of 
a grain three times daily) have been found of value. If, coin- 
cident with the labyrinthine affection, the tympanum is also 
involved, this should be treated as a simple middle-ear inflam- 
mation, according to the rules already laid down, the local 
measures employed in no way interfering with the lesion 
within the labyrinth. The use of mercurial ointment about 
the ear is probably of but little value, better results being 
obtained by giving a mercurial by the mouth. In recent 
cases, where it is desirable to obtain the constitutional effect 
of mercury as soon as possible, the process of general inunc- 
tion, or of baths of mercurial vapor, may be used, as in the 
treatment of any manifestation of a recent specific infection. 
Locally, however, the use of mercurial ointment is of no 
value. In the hereditary cases the treatment should be di- 
rected to an improvement of the general health, as well as 
toward the specific taint. In addition to the iodide of potas- 



556 SPECIFIC INFLAMMATION OF THE LABYRINTH. 

sium, cod-liver oil, hypophosphites, iron, etc., should be given, 
and the diet of the patient should be as liberal as possible. 
The surroundings of the patient should receive attention, and 
every effort should be made to keep him in a condition which 
will render him less susceptible to the action of the heredi- 
tary taint. 

Strychnine is of value in some cases, but must be given in 
full doses. For an adult not less than a fifteenth of a grain 
should be given three times daily. The initial dose must, of 
course, be small, but the quantity should be rapidly increased. 
The appearance of unpleasant symptoms will be an indication 
for reducing the dose. As already stated, the results will be 
to an extent uncertain. 



CHAPTER XXXV. 

INFLAMMATION OF THE LABYRINTH SECONDARY TO CHRONIC 
SUPPURATIVE AND NONSUPPURATIVE INFLAMMATION OF 
THE TYMPANUM. 

Pathology. — Where the tympanic structures have been 
subjected for a long time to an abnormal degree of pressure 
from an adhesive process within the tympanum, certain 
changes take place within the bony capsule, both as the 
direct result of mechanical pressure and also from the ab- 
lation of function which this increased pressure causes. 
Owing to the augmentation in the tension within the laby- 
rinth, the delicate terminal filaments of the auditory nerve in 
the lower part of the cochlea and in the vestibule may be 
completely destroyed. On the other hand, the increased 
tension may prevent the conduction of aerial vibrations to 
these nerve-end organs, and, on account of the disease in the 
middle ear, they may undergo atrophy from disuse, so that 
if the pressure is removed and the normal tension within the 
labyrinth is restored, they will be no longer able to perform 
their function. The inflammatory process within the tym- 
panic cavity may be propagated to the adjacent labyrinthine 
parts by contiguity of structure. This is especially true in 
those cases of otitis media arising from the deposit of new 
connective tissue in the niche of the oval or round window. 
By extension, the parts beyond the foot plate of the stapes 
undergo, similar changes ; the vestibular walls become thick- 
ened, the process at first resulting in thickening of the peri- 
osteum, and subsequently in the deposit of new osseous 
tissue, thus encroaching upon the lumen of the vestibule. 
Similar changes about the round window result in an en- 
croachment upon the lumen of the first turn of the cochlea. 
This process is quite characteristic of proliferous otitis media. 
It is also, as Politzer has recently shown, quite commonly 
found in advanced life, and constitutes the prominent lesion 
in the presbycusis. 

(557) 



558 INFLAMMATION OF THE LABYRINTH. 

The changes which take place within the labyrinth in 
chronic purulent otitis media are usually less marked than in 
the nonsuppurative form of the affection. Those met with in 
residuary cases, where the purulent inflammation has run its 
course, are due to pressure or disuse, or to both combined. 
While there is active suppuration, an actual infection of the 
labyrinthine structures may take place through the fenestra 
ovalis or the fenestra rotunda, leading to a purulent inflamma- 
tion of the labyrinth. This may be transmitted, either through 
the blood vessels or through the aquasductus vestibuli or 
aquasductus cochleae, to the meninges, and cause a leptomenin- 
gitis. In the labyrinth such a purulent inflammation results 
in a disintegration of the structures involved. This would 
mean complete destruction of the labyrinth if the entire re- 
gion were affected. Fortunately, however, such an inflamma- 
tion is frequently confined to the immediate neighborhood of 
the external labyrinthine wall, and its destructive effects are 
limited to the vestibular structures and to those elements 
lying in the first turn of the cochlea. Meningitis seldom 
occurs by infection through the lymph channels of the inter- 
nal ear, and this of itself argues strongly against any free 
anastomosis between the vessels of the middle ear and those 
of the labyrinth immediately adjoining. Suppuration within 
the tympanic cavity may produce changes due to pressure 
alone, infection not taking place. In such an event the parts 
may be restored to their normal condition by treatment of the 
tympanic affection, and will then resume their proper function. 

In addition to these structural changes, recognizable under 
the microscope in pathological specimens, we must remember 
that in many cases, probably, in which the middle ear is the 
seat of a chronic inflammatory process, the labyrinthine struc- 
tures in the immediate vicinity of the tympanum become 
congested, and remain in this condition for a considerable 
period, without actual tissue metamorphosis. The vascular 
disturbances consist either of increase in the arterial sup- 
ply, or a diminution of the venous outflow, augmenting the 
labyrinthine tension and giving rise to symptoms, although 
microscopic specimens would reveal no structural changes. 
We are warranted, however, in the supposition that these 
conditions are present from the history of certain cases. 

Symptomatology. — The exact line of demarcation between 
symptoms dependent upon middle-ear or labyrinthine changes 



SYMPTOMATOLOGY— TINNITUS. 5 59 

can not be drawn. All symptoms of impairment or perver- 
sion of function must, strictly speaking, be relegated to the 
perceptive tract, and it is difficult to say when they are pro- 
duced by mechanical irritation simply, from alterations in the 
tension of the conducting apparatus, and when certain changes 
have actually taken place in the labyrinth itself. The most 
constant symptom is undoubtedly the presence of subjective 
noises. In the early stages of a nonsuppurative otitis media 
the persistence of tinnitus should be looked upon as an indi- 
cation that the labyrinth is at least congested, and, unless 
prompt measures are taken for the relief of the condition, 
must soon become the seat of organic changes. The sub- 
jective noises vary in character and in intensity. At first they 
are intermittent, occurring chiefly when the recumbent posi- 
tion is assumed, as this posture favors a determination of 
blood to the head. In neurotic individuals any severe nerv- 
ous strain, or even physical exertion, will serve to increase 
them. The same is true of impairment of the general health, 
or asthenia following a severe illness. 

When these noises are intermittent, and due chiefly to 
congestion, they are frequently synchronous with cardiac 
pulsations ; but as the disease advances this pulsating tin- 
nitus diminishes, and is replaced by a constant high-pitched 
musical sound as the lower portion of the receptive tract 
becomes involved. These patients also complain that, in ad- 
dition to this high-pitched musical note, they hear at irregu- 
lar intervals loud, low-pitched sounds, variously described 
as rumbling, roaring, thumping, or booming noises. We 
may surmise that these are produced by changes within the 
cristas and acusticas. In those cases where the tympanic 
process is confined chiefly to the region of the oval or 
round windows the interference with sound transmission 
may be so slight as to occasion very little impairment in the 
hearing, and the subjective noises may constitute the sole 
symptom of which the patient complains, the labyrinthine 
structures being involved at a very early period. As the 
process advances, the subjective noises change their charac- 
ter, becoming of lower pitch, and finally they may disappear 
entirely, owing to a complete destruction of the nerve fila- 
ments. This same general train of symptoms is occasionally 
met with in cases of chronic suppurative inflammation where 
the process is still active, or in residuary cases, but is always 



560 INFLAMMATION OF THE LABYRINTH. 

present to a much less degree than in the instances of hyper- 
plastic otitis media. The reason for this is probably twofold, 
the first being that the process within the tympanum has 
been followed by destruction of portions of the conducting 
mechanism, and increased labyrinthine tension may be pres- 
ent to only a very slight degree. As a second reason, we 
should remember that the inflammatory process within the 
labyrinth itself is not of such a character as to lead to the 
deposit of new tissue, but to an increase in the amount of 
perilymph. This increase takes place slowly, and is com- 
pensated for by the passage of the fluid outward into the 
endocranial lymphatic spaces. 

In addition to the tinnitus, disturbance of the equilibrium 
is frequently complained of. This points to the invasion of 
that portion of the labyrinth in immediate relation with the 
semicircular canals, as well as involvement of the canals 
themselves. The vertigo may be constant or intermittent, oc- 
curring only upon some sudden change in the position either 
of the entire body or of the head, or it may be due to visceral 
disturbances. Sudden changes in intratympanic pressure do 
not under normal conditions cause vertigo ; but when the ap- 
paratus which presides over the static condition of the body 
is in unstable equilibrium, even a slight disturbance may cause 
giddiness. A sudden closure of the Eustachian tube — the re- 
sult of an acute rhinitis or naso-pharyngitis — or a powerful 
effort at blowing the nose, or a severe fit of coughing, may 
so alter the pressure as^to bring on an attack of dizziness. 
Any process which suddenly increases the blood pressure 
within the labyrinth is capable of bringing on vertigo. Here 
we may mention violent exercise, suddenly lowering the 
head in stooping, intense mental excitement, as either rage or 
grief, etc. 

The vertigo seldom persists, but disappears in late stages 
of the disease. The impairment of hearing varies greatly in 
degree, and the subjective symptoms may cause the patient 
to seek relief before he has noticed any change in the power 
of audition. The reason of this is that the perception of 
the highest notes of the musical scale is of little use in the 
ordinary vocations of life, and conversation may be perceived 
without difficulty, although the upper tone limit is consid- 
erably lowered. 

The clinical history detailed above presupposes the in- 



INVOLVEMENT OF OPPOSITE EAR. 561 

volvement of but one ear. Sooner or later the organ of the 
opposite side becomes involved, and then the impairment in 
function becomes decidedly noticeable and increases with 
great rapidity. The balance of evidence at present seems to 
favor the view that the involvement of the ear of the oppo- 
site side is due to an extension of the process from the one 
first attacked, rather than that it is dependent upon an inflam- 
matory process similar in character but of primary origin. 
This extension can readily be understood if we remember 
the crossing of the fibres of the eighth nerve in the medulla, 
through which the cortical auditory region receives fibres 
from the labyrinth of either side, but chiefly from the oppo- 
site labyrinth. An involvement of this principal terminal ap- 
paratus would cause degenerative changes to take place in 
the centre itself. These, in turn, would excite certain dis- 
turbances in that portion of the cortex deriving its supply 
from the nerve of the side corresponding to the cortical area, 
thus ablating the function of this portion of the cochlea of 
this side. Clinical observation shows that in a large propor- 
tion of cases of hyperplastic otitis media, with complicating 
labyrinthine involvement, the labyrinthine changes in the ear 
last affected are more extensive than those in the organ first 
involved. Of twenty-six of my own cases, sixteen exhibited 
this condition.* The tympanum also becomes involved sec- 
ondarily, but to a much less extent than the labyrinth, and 
the impairment of function seems to be due chiefly to the 
labyrinthine changes. These alterations occur so rapidly 
that the patient not infrequently presents with the history 
that the ear first involved is at present of the most use to 
him. It is of great importance to obtain a correct history 
of the case, and we should learn definitely, if possible, in 
which ear the impairment of hearing began, and at what 
period. Unless great care is taken to obtain these data a 
grave error may be made. 

After the terminal filaments of the auditory nerve have 
been the seat of changes for a considerable period, the sub- 
jective noises, which were at first distressing, become less 
severe, owing to the complete ablation of function of this por- 
tion of the cochlea. The spontaneous cessation of tinnitus in 
one ear furnishes a clew to the information desired, and it is 



* New York Eye and Ear Infirmary Reports, 1894, vol. ii, p. 62. 
33 



562 INFLAMMATION OF THE LABYRINTH. 

usually the case that the organ first involved causes less dis- 
tress from this cause than does its fellow. Where the tym- 
panic process is marked in the ear last involved, the symp- 
toms differ in that the impairment of hearing is usually about 
equal upon the two sides, or audition is perhaps slightly bet- 
ter upon the side last involved. 

Diagnosis. — A. Physical Examination. — Upon inspecting the 
ear we have presented a picture of chronic catarrhal inflam- 
mation, or the various changes resulting from a suppurative 
process. In the nonsuppurative variety the parts may vary 
but little from the normal standard, as far as appearances are 
concerned, the reason being that the pathological changes 
take place mostly at the oval and round windows. The more 
external parts of the conducting mechanism may be but little 
affected. The color, density, lustre, and position of the drum 
membrane may be within normal limits, provided the changes 
have been hyperplastic from the start. In those cases sec- 
ondary to a hypertrophic process the position of the drum 
membrane is usually abnormal ; it is commonly retracted to a 
greater or less degree, and presents variations in density in 
different areas, while the breadth of the malleus handle is 
either greater or less than under normal conditions, from a 
rotation of this ossicle upon its long axis. This has been 
fully described in a previous chapter. 

Where the internal ear is involved as the sequel to a sup- 
purative inflammation which has run its course, the appear- 
ances vary according to the amount of destruction which has 
taken place. The postero-superior quadrant is the region to 
be particularly inspected as throwing light upon the probable 
cause of the involvement of the perceptive portion of the 
auditory system. We may find the stapes forced deeply into 
the oval niche and fixed by adhesions, which bind the crura 
firmly to the borders of the pelvis ovalis, or a tense posterior 
fold may cause a similar condition. The niche of the round 
window is quite frequently in view, and should always be 
examined for adhesions, as these may play an important part 
in the production of the symptoms. Where the stapes has 
become separated from the incus, during the course of a sup- 
purative inflammation, the condition of the other ossicula may 
be practically disregarded, since the structures within the pel- 
vis ovalis and niche of the round window alone affect the con- 
dition of the labyrinth. In the nonsuppurative cases it is 



FUNCTIONAL EXAMINATION. 563 

important to determine whether the middle-ear affection has 
become quiescent, or whether it is still active and progress- 
ive. To decide this definitely is often impossible ; although 
hyperemia at the inner extremity of the bony meatus, close 
to the tympanic ring, may usually be looked upon as an evi- 
dence that the tympanic affection is still active, while, if the 
parts are pale, the process is probably quiescent, and the laby- 
rinthine changes are not liable to be augmented by the fur- 
ther progress of the middle-ear lesion. 

B. Functional Examination. — The hearing is impaired both 
for sharp sounds and for whispered or spoken w r ords. It 
may be roughly stated that where the labyrinthine involve- 
ment is extensive, sharp noises are relatively more poorly 
heard than speech, the converse being true when a tympanic 
affection predominates. 

The lower tone limit is elevated, the upper tone limit re- 
duced, the degree varying with the extent of the labyrinthine 
lesion ; bone conduction is decidedly diminished or may be 
entirely absent. Rinne's experiment will be negative for the 
lower notes of the scale, becoming positive as the test is made 
with the higher forks. It is now important to determine in 
any given case how much of the impairment depends upon 
the condition within the tympanum and how much upon the 
secondary labyrinthine changes. If we compare the degree 
of defective audition for whispered or spoken words with the 
point in the musical scale at which Rinne's experiment be- 
comes positive, we have an estimate of the relative amount 
of middle -ear and labyrinthine involvement. Where this 
point lies high in the musical scale in cases where the func- 
tion is impaired to a marked degree, we are warranted in 
the conclusion that the chief trouble lies within the tympa- 
num. Confirmatory of this we find the upper tone limit but 
slightly lowered, and bone conduction either normal or but 
little impaired. Naturally the age of the patient must be 
taken into account in drawing these deductions. If, on the 
other hand, we have to deal with a patient who hears the 
whisper only when the words are repeated close to the ear, 
and Rinne's experiment becomes positive in the lower portion 
of the scale, the tympanum is not the part most involved. In 
such an instance we should expect to find a marked lowering 
of the upper tone limit, and poor bone conduction. In de- 
ciding this question, it is well to make several examinations, 



564 INFLAMMATION OF THE LABYRINTH. 

since any sudden disturbance within the tympanum causing a 
temporary increase in labyrinthine pressure might mislead us. 
The results obtained from functional examination conducted 
in this manner, taken in connection with the history of the 
case, the age of the patient, etc., will seldom fail to render 
the diagnosis clear. Certain symptoms of which the patient 
complains, such as the cessation of subjective noises, the 
presence or absence of paracusis Willisii, evidences of audi- 
tory fatigue, and marked variations in the hearing power 
dependent upon meteorological changes, are also of value. 
With reference to this last symptom, I feel certain that vari- 
ations following changes in the weather are quite as charac- 
teristic of an affection of the cochlea as of one of the middle 
ear. This point has been sufficiently considered in a previ- 
ous section. 

The reaction of the auditory nerve to electrical stimuli is 
of diagnostic value. If a hyperassthetic condition is present, 
this denotes activity or progression of the disease, but does 
not locate it definitely, since this hyperassthesia may depend 
upon the excitation of the terminal filaments by a progressive 
tympanic inflammation, or it may be the result of an active 
process within the labyrinth. The inspection of the parts 
will usually enable the surgeon to decide whether the tym- 
panic inflammation is active or quiescent, and in this way to 
determine the cause of the hyperaesthesia. 

It should be the rule to investigate both ears with equal 
care, otherwise incipient involvement may be overlooked. 
Galvanic hyperassthesia upon one side may depend upon in- 
flammation of the opposite tympanum. 

Prognosis. — Any implication of the peripheral filaments 
of the auditory nerve, secondary to changes within the mid- 
dle ear, constitutes in every case a grave condition. The ulti- 
mate result must be considered both with reference to the 
further progress of the disease and to correcting the effects 
already produced. In the cases following a destructive in- 
flammation within the tympanum, a steady advance of the 
symptoms is seldom looked for. We occasionally meet with 
instances in which a preceding suppurative otitis media af- 
fecting one side only, produces late in life certain disturbances 
in the organ upon the opposite side. When this occurs the 
prognosis as regards the healthy ear is of chief moment, the 
other organ having been practically useless for a long time. 



PROGNOSIS-TREATMENT. 



565 



If unchecked by proper measures a steady advance must be 
expected. In nonsuppurative cases the involvement of one 
ear is followed sooner or later by a corresponding process 
upon the opposite side. In unilateral cases, if we can do 
nothing to improve the condition of the affected organ, the 
early adoption of measures directed to the removal of its effect 
upon the opposite ear may stop the progress completely. In 
bilateral cases we may usually assume that where the tym- 
panic disease predominates upon the side first involved, its 
proper treatment will not only improve the function of both 
organs, but will stop the progress of the disease completely. 
With regard to the progress of the labyrinthine lesion in the 
organ first affected, this, almost without exception, advances, 
unless checked artificially, until the function of the ear is en- 
tirely ablated. The probable result of treatment will depend 
upon the extent to which the process has advanced before the 
case comes under observation. Where we judge that a com- 
paratively small portion of the cochlea is involved, we may 
hope to restore the function to a great degree. If extensive 
changes have taken place, complete retrogression must not 
be hoped for. But a considerable amelioration of the symp- 
toms may occur even in cases of long standing. In general, 
those cases dependent upon suppurative disease are much 
more favorable than those where connective-tissue hyperplasia 
has occurred primarily. 

Treatment. — First of all we must remove any condition 
within the tympanum which might cause labyrinthine 
changes. In other words, treatment directed to the middle 
ear is not contraindicated in instances of mixed disease, ex- 
cept in cases where the labyrinthine condition is the most 
prominent feature and has existed for so long a time as to 
render its relief impossible even if the tympanic lesion could 
be overcome. Adhesions must be absorbed or divided ac- 
cording to their density. In suppurative cases surgical 
measures are practically the only ones at our disposal, and 
the stapes and the membrane about the round window must 
be relieved of any increased tension. Tense bands must be 
divided according to the principles of aseptic surgery, and 
this process continued until the niche of the oval and round 
window is perfectly free. In the nonsuppurative cases sur- 
gical measures may be called into requisition, although here 
with less promise of success than in the preceding instances. 



566 INFLAMMATION OF THE LABYRINTH. 

This subject has been thoroughly dealt with under Middle 
Ear Operations, and need not be repeated. The procedures 
are to be instituted both for the organ first affected and for 
its feljow of the opposite side. Concerning the administra- 
tion of drugs, pilocarpine seems to be the remedy best 
adapted to these cases. It is to be administered preferably 
by the mouth, beginning with doses of one eighth to one 
sixth of a grain twice or three times daily, the amount to be 
increased according to the toleration of the patient. If bene- 
fit is to be obtained, the constitutional effects of the drug must 
be produced, and its administration continued for a period of 
two months, and in many cases longer. No improvement 
should be expected under two weeks or a month, and it is 
frequently delayed beyond this time. 

Where one ear has been considered useless by the patient 
for many years, a condition of torpidity of the auditory nerve 
and corresponding centres manifests itself. This is best com- 
bated by the administration of strychnine in full doses, begin- 
ning with one fortieth of a grain three times daily, increasing 
to one twentieth or one fifteenth if the drug is well borne. 
This drug may be advantageously administered in connection 
with pilocarpine. 

Where there is a history of either hereditary or acquired 
specific disease the iodides in full doses frequently produce 
remarkable results. Much has been written of late upon 
the treatment of these cases by sonorous vibrations by means 
of the phonograph or some similar instrument. This form of 
treatment is by no means new, the idea being mentioned by 
Toynbee,* who reports a case of great improvement follow- 
ing the use of the conversation tube for a considerable period 
of time. In this instance the human voice was the agent em- 
ployed. Later, tuning forks were used for the same purpose, 
the fork being maintained in vibration before the patient's ear 
for a certain length of time, and effecting both massage of 
the rigid ossicular articulations and stimulation of the audi- 
tory nerve itself. The employment of the phonograph, vibro- 
phone, vibrometer and similar devices for effecting the same 
result, is merely an application of this principle, the apparatus 
used being of little importance. 

There is evidence to show that by following this plan sub- 

* Diseases of the Ear, p. 433. 



TREATMENT— GENERAL. 567 

jective noises are reduced in intensity and the hearing in cer- 
tain cases improved. For a considerable period of time I have 
advised the use of some simple form of conversation tube, the 
patient being read to by an attendant for perhaps ten or fif- 
teen minutes twice daily, in a tone of voice that can be easily 
perceived. Any words which are not clearly heard should 
be repeated distinctly at least ten times. In this way the 
torpidity of the receptive centre is overcome and the patient 
learns to interpret correctly the words which he hears, al- 
though they may not be perfectly heard. The process is 
exactly similar to that of a child learning to talk, or of an 
adult learning a foreign language, the sensorium being 
really educated so as to correctly interpret the perverted 
auditory stimuli. 

The relief of subjective noises seldom forms a prominent 
indication for treatment in cases of advanced labyrinthine 
disease. Where these are distressing, however, a period of 
temporary relief may usually be obtained by the administra- 
tion of large doses of hydrobromic acid, and it is wise in all 
cases to employ this drug when the noises first appear. If 
they are allowed to continue, the higher centres become so 
irritated that the removal of the primary cause of the disease 
may fail to relieve this distressing symptom completely. Con- 
cerning the effect of climate upon the progress of the affec- 
tion but little is actually known, and I have never considered 
the matter of climate of sufficient importance to insist upon a 
change of residence for the aural affection alone. Of much 
more importance is the general condition of the patient. 
Overfatigue, mental strain, irregularities in diet, or the ex- 
cessive use of stimulants must be positively interdicted. The 
employment, except when it is imperative, of any drugs — 
such as quinine or salicylic acid — which are known to cause 
an intense congestion of the labyrinth, must also be forbidden, 
since their ingestion, even in small doses, may excite the pro- 
cess to renewed activity. Diathetic conditions must be con- 
trolled, particularly those of a gouty or rheumatic character. 

Treatment of the upper air passages, in the hope of im- 
proving the aural condition, is useless when these measures 
are undertaken for this purpose alone. It is of great impor- 
tance, however, that deviations from the normal standard in 
these regions, which produce local symptoms — such as fre- 
quent colds, imperfect nasal respiration, etc. — should receive 



568 INFLAMMATION OF THE LABYRINTH. 

proper treatment, as variations in the circulation within the 
labyrinth are thus avoided. 

Where extensive involvement of the labyrinth of both 
sides is present, but little relief can be hoped for by the cor- 
rection of any pathological condition within the tympanum ; 
and in certain instances, especially in old people, surgical in- 
terference is positively contraindicated, as the progress of 
the disease is usually rendered more rapid by these measures. 
In cases of extensive unilateral involvement, such measures 
may be justifiable in the hope of preserving the opposite ear, 
but should not be instituted unless there is positive evidence 
that the diseased organ is affecting the healthy one. 



CHAPTER XXXVI. 

ACUTE INFLAMMATION OF THE LABYRINTH SECONDARY TO 
ACUTE PURULENT OTITIS MEDIA. 

Etiology . — This form of inflammation of the labyrinth is 
usually confined to those cases in which the middle-ear affec- 
tion depends upon an acute infectious disease, such as scarlet 
fever, diphtheria, measles, epidemic influenza, cerebro-spinal 
meningitis, or typhus fever. It may follow a severe attack of 
suppurative otitis media, developing from exposure to cold, 
from a traumatic cause, such as the accidental introduction of 
fluid into the tympanum, or rupture of the membrana tym- 
pani. It occurs most frequently in child life, at which period 
the petrous portion of the temporal separating the labyrinth 
from the middle ear is thinner and of less density than later 
in life. In order that the entire auditory mechanism should 
be involved in an inflammatory process, the infection must be 
of great virulence, and this depends upon the severity of the 
acute infectious disease. 

Pathology. — This condition has been called, not inappro- 
priately, panotitis. As the result of infection within the mid- 
dle ear the softer structures rapidly break down, while the 
firmer osseous tissue becomes carious, and are either com- 
pletely destroyed or suffer a considerable loss of substance. 
The periosteum covering the inner tympanic wall takes part 
in these changes, and not infrequently an acute inflammation 
of the underlying osseous tissue results. The propagation 
of the condition to the labyrinth may take place either di- 
rectly through the diseased bony wall or at the labyrinthine 
windows. Post-mortem examination frequently shows a de- 
struction of the membrane of the round window, or a loss of 
substance at the stapedio-vestibular articulation, the infectious 
material having entered through these channels. The tissue 
changes which take place do not differ from those observed 
in the middle ear. Microscopic investigation reveals the 
presence of the bacilli of suppuration both in the blood ves- 

(569) 



5JO ACUTE INFLAMMATION OF THE LABYRINTH. 

sels and in the tissues. Local necrosis occurs early, and the 
firm osseous tissues either disintegrate and are thrown off in 
the profuse secretion incident upon the inflammatory process, 
or the necrosis may result in the formation of a sequestrum, 
which is either discharged spontaneously or is removed by 
surgical interference. The condition may extend from the 
labyrinth to the meninges, either along the sheath of the 
auditory nerve or through the vestibular or cochlear aque- 
ducts, causing a purulent meningitis. These extensive changes 
may cause partial or complete destruction of the end organ 
of the auditory nerve. During the reparative process new 
osseous tissue may be deposited and obliterate the labyrin- 
thine cavity to a greater or less extent. 

Symptomatology. — Occurring in young subjects most fre- 
quently, the symptoms depend upon the intense systemic in- 
fection rather than upon the involvement of the terminal 
portion of the auditory apparatus. The involvement of the 
labyrinth in consequence of an acute process within the mid- 
dle ear announces itself in older subjects by the sudden ap- 
pearance of giddiness, intense tinnitus, and great impairment 
of hearing, the function of the ear being completely abolished 
in many cases. When the inner wall becomes involved in this 
manner, facial paralysis is not uncommon, owing to a partial 
destruction of the aquseductus Fallopii, exposing the facial 
nerve to infection. Occasionally dehiscences are found in 
the osseous covering of the facial nerve when there has been 
no pathological process, in which case a simple inflammation 
of the middle ear produces this symptom without causing 
a loss of substance in the wall of the aquasductus Fallopii. 
Hence, facial paralysis alone is not necessarily an evidence 
that the disease has involved the bony walls. The interfer- 
ence with equilibrium may depend upon the entrance of the 
infectious material into the vestibule, or the horizontal semi- 
circular canal situated high up on the inner tympanic wall 
may be the seat of involvement ; in the latter case disturb- 
ance of equilibrium alone is present, while the function of 
audition is scarcely perverted or interfered with. The most 
usual avenue of extension is through the oval and round 
windows, with involvement of the vestibule. An inflam- 
matory process in this location produces the characteristic 
symptoms first mentioned, namely, vertigo, tinnitus, and 
impairment of hearing. As the case progresses the vertigo 



SYMPTOMATOLOGY— DIAGNOSIS. 



571 



is the first symptom to disappear ; next the tinnitus becomes 
less severe, but the impairment of hearing is permanent. 
The membranous portions of the cochlea may be completely 
disintegrated, and the bony passages are sometimes obliter- 
ated by the deposit of new osseous tissue. In many instances 
a large part of the petrous portion of the temporal bone is 
thrown off as a sequestrum. Since the petrous bone lodges 
the internal carotid artery and the internal jugular vein, 
severe haemorrhage from the ear is not an infrequent symp- 
tom of this extensive destruction. If either the carotid or 
jugular is eroded, this haemorrhage is usually fatal. From 
the proximity of the cranial contents, direct infection of the 
meninges may follow, with the characteristic symptoms of 
meningitis. It is probable that a localized inflammation of 
the labyrinthine structures in the immediate neighborhood of 
the fenestra rotunda sometimes occurs, without spreading to 
the entire labyrinth. In those cases which do not terminate 
fatally, the hearing for the upper portion of the musical scale 
remains greatly impaired, and there is but little promise of a 
favorable termination under any plan of treatment. A por- 
tion of specialized end organ of the auditory nerve has been 
completely destroyed by the disease, and manifestly can not 
be regenerated by therapeutic measures. Any portion of the 
cochlea which has remained intact may still respond to the 
stimuli of sonorous vibrations, and the removal of certain 
conditions which interfere with its proper action may pre- 
serve the remnant of the auditory function. 

Diagnosis. — A. Physical Examination. — Speculum examina- 
tion reveals but little in these cases. The picture is one of a 
suppurative otitis media of great severity, and in the early 
stages this is all that can be made out. At a later period the 
presence of carious bone gives rise to the formation of exuber- 
ant granulations in the tympanic cavity, while careful exami- 
nation with the probe may reveal denuded areas upon the 
inner tympanic wall. The profuse discharge is also indica- 
tive of extensive tissue necrosis, and where carious bone is 
present the discharge frequently possesses a strong, disagree- 
able odor. The presence of this offensive discharge is not an 
invariable evidence of dead bone, but should lead to a strong 
suspicion of its presence. 

B. Functioiial Examination. — In young subjects an exami- 
nation of this kind is manifestly impossible. Occurring in 



572 ACUTE INFLAMMATION OF THE LABYRINTH. 

patients of sufficient age to answer questions intelligently, it 
is often of great service in enabling us to determine the pres- 
ence or absence of the condition in question. Bone conduc- 
tion is either completely abolished or greatly reduced. The 
upper tone limit is lowered to such a degree that the ear may 
respond to no vibrations beyond two thousand per second. 
This fact is explainable on anatomical grounds. Low tones, 
on the contrary, are fairly well heard, although the extensive 
destruction which has taken place within the tympanum ren- 
ders the ear less susceptible to these than under normal con- 
ditions, or in cases of primary labyrinthine disease in which 
the conducting mechanism is not affected. If we add to this 
complete loss of perception of high musical notes the loss of 
bone conduction and the intense vertigo, we have a combina- 
tion of symptoms which can mean nothing but labyrinthine 
involvement. 

Prognosis. — The prognosis is absolutely unfavorable as to 
the complete restoration of the function of the organ, the 
hearing being completely destroyed in a large majority of 
cases. As to life, the outlook is equally grave, especially in 
young subjects. In adults, extension to the meninges is less 
common, and a favorable termination may be hoped for. 
Much depends upon the degree of infection, and this varies 
with the disease which has caused the inflammation within 
the tympanum. The poisoning is usually so profound as to 
give little hope for the recovery of the hearing, even if the 
aural complication does not prove fatal. Complete ablation 
of audition is less liable to take place in adults than in chil- 
dren, but profound interference with function must always be 
looked for. At an early age this termination means deaf- 
mutism, and it is our duty to bear this in mind in giving an 
opinion. 

Treatment. — After the labyrinth has once become in- 
volved nothing can be done to stay the progress of the in- 
flammation. Our duty lies chiefly in the adoption of prophy- 
lactic measures, in all cases of severe suppurative otitis, for 
the prevention of such an infection. These are embraced 
under the head of thoroughly cleansing the ear by frequent 
syringing, keeping the tympanic cavity as nearly as possible 
in an aseptic condition. Too much stress can not be laid upon 
this point, since the practitioner is usually so much occupied 
with the general disease that he can give but little attention 



TREATMENT. 



573 



to the ears. After the labyrinth has become involved the parts 
should still be kept thoroughly cleansed by syringing, but be- 
yond this nothing can be done. Where tinnitus is the promi- 
nent symptom, large doses of hydrobromic acid or of sodium 
bromide give the most relief. Extension to the meninges may 
be combated by the application of the ice cap to the head, free 
purgation, and absolute rest. During the acute stages noth- 
ing can be done to confine the involvement of the labyrinth 
to a particular area. After the acute symptoms have passed 
away it is advisable to administer the muriate of pilocarpine, 
either hypodermically or by the mouth. The result is uncer- 
tain, but in several cases the author has seen excellent results. 
Strychnine should also be given in full doses after the acute 
symptoms have passed. 



CHAPTER XXXVII. 

INVOLVEMENT OF THE PERCEPTIVE MECHANISM IN THE 
ACUTE INFECTIOUS DISEASES. 

During the course of scarlatina, diphtheria, measles, 
mumps, typhus or typhoid fever, variola, influenza, etc., the 
organ of hearing is not infrequently the seat of marked 
pathological changes. In scarlet fever, diphtheria, measles, 
and influenza, and to a less degree in variola, the middle ear 
is the part first attacked in most cases, and any labyrinthine 
involvement is due to an extension of the tympanic inflam- 
mation. We meet with instances, however, in which the 
specific poison exerts a direct influence upon the labyrinth, 
in some cases the middle ear remaining healthy, while in 
others there has evidently been a double infection, the laby- 
rinthine process in no way depending upon the changes which 
have taken place in the tympanum. 

Pathology. — In the diseases already enumerated the poison 
is conveyed to the labyrinth through the blood current, and 
excites an inflammation of the tissues which line its bony chan- 
nels, in some cases causing a disintegration of a large portion 
of the terminal apparatus of the auditory nerve, while in 
others the local process does not reach this degree, but results 
in an effusion of fluid into the labyrinthine cavity, with the 
result of increasing the tension upon the contained parts, as 
well as of the membranes covering the round and oval win- 
dows. If the effusion is sufficient in amount to overcome the 
elasticity of these limiting membranes, the function of the 
labyrinth is for a time perverted, particularly for those parts 
lying immediately in the neighborhood of the round and oval 
windows. It is probable that the small capillary channels of 
the aqueducts which permit any excess of perilymph to pass 
into the intracranial lymph spaces are partially occluded, and 
hence relief to pressure in this direction is impossible. Under 
these conditions the disturbance of function depends entirely 

(574) 



SYMPTOMATOLOGY— DIAGNOSIS. 575 

upon the invasion of the labyrinthine cavity, even although 
the middle ear may have been the seat of changes as well. 

Symptomatology. — These cases are characterized by vary- 
ing degrees of impairment of hearing and rather moderate 
subjective noises. In the milder cases in adult life the pa- 
tients hear more poorly in a noise than in a quiet place. The 
impairment of hearing is particularly marked in general con- 
versation. In other instances, and when the primary disease 
which has produced the condition has been severe, a high 
degree of deafness is present, the voice being heard only 
when the patient is spoken to loudly in the immediate vicinity 
of the ear. The exanthemata are particularly prone to affect 
the organ of hearing in this way, and are most common in 
childhood ; at this age such a condition must lead to mutism 
unless speedily remedied, and the recognition of the nature 
of the process is of greater importance in childhood on this 
account. 

Diagnosis. — The diagnosis in these cases depends upon 
the fact that the middle ear is either perfectly healthy, or 
presents changes which are evidently incapable of producing 
the degree of functional impairment present. The functional 
examination is characteristic of labyrinthine changes rather 
than of those met with in a lesion of the conducting appara- 
tus. The lower tone limit may be normal or but slightly 
elevated, even although extensive changes have occurred 
within the tympanum. The upper tone limit is greatly low- 
ered ; bone conduction reduced in spite of the presence of a 
tympanic lesion, or nearly absent where the tympanum is in 
a healthy condition. Not infrequently tone gaps are present 
in the upper portion of the musical scale. 

Prognosis. — When changes are of recent origin, we are 
warranted in believing that considerable improvement may 
follow proper therapeutic measures, and in cases of long 
standing it is by no means impossible to improve the condi- 
tion very materially. In childhood, particularly, internal 
medication is followed by the happiest results, and the pa- 
tients should always have the benefit of the doubt, even al- 
though the case may seem apparently hopeless. 

Treatment. — For the reduction of labyrinthine pressure 
and the absorption of the exudation, the administration of 
pilocarpine first in small doses — the amount being rapidly 
increased as the patient becomes accustomed to its use — 



576 THE EFFECT OF ACUTE INFECTIOUS DISEASES. 

causes a marked improvement in the hearing, and the im- 
provement is usually permanent. In cases of long standing 
the torpidity of the nerve is to be combated by the use of 
strychnine as well. This drug must be administered in much 
larger doses than those ordinarily recommended in order 
that this effect may be produced. An additional indication 
for its administration is to combat the depression which the 
prolonged use of the pilocarpine frequently causes. It is 
scarcely necessary to say that the most careful attention 
must be paid to the general condition of the patient, and in 
the case of children every effort is to be employed to educate 
the power of audition as it improves. 

Having considered involvement of the perceptive appara- 
tus in acute infectious diseases from a general point of view, 
a few remarks may not be out of place in regard to some of 
the particular changes following certain of these maladies. 

Mumps. 

Epidemic parotiditis is particularly prone to affect the 
labyrinthine structures rather than the middle ear. Recent 
investigations seem to prove clearly that this local inflamma- 
tion is due to infection from the blood current in precisely 
the same manner as in a complicating orchitis. The effect 
upon the perceptive apparatus is usually very profound, and 
its occurrence in early life is a not infrequent cause of deaf- 
mutism. 

The symptoms detailed above are all characteristic of 
labyrinthine disease dependent upon this cause. The same is 
true of the diagnostic measures employed and the therapeu- 
tic means at our disposal. 

Regarding the prognosis in these instances, treatment is 
followed by the happiest results if instituted early. When 
the patient does not come under treatment until a considera- 
ble time has elapsed, the complete restoration of function can 
not be hoped for, although moderate improvement may be 
expected. 

Typhus and Typhoid Fever. 

In typhus or typhoid fever interference with sound per- 
ception is probably due to the changes which the specific 
poison of the disease causes in the cerebrum itself rather than 
to any effect upon the terminal filaments of the nerve. That 



INFLUENZA— DIPHTHERIA— EPIDEMIC MENINGITIS. 



577 



this is the case seems to be borne out when we consider the 
degree of impairment of hearing which these patients fre- 
quently present, and its disappearance during the period of 
convalescence. 

Epidemic Influenza; Diphtheria. 

In epidemic influenza, and in some cases of diphtheria, it is 
probable that the perceptive apparatus occasionally suffers 
through changes in the auditory nerve trunk similar to those 
occasionally found in the optic nerve following these diseases. 
These are of the nature of a peripheral neuritis, and involve 
the nerve trunk to a varying degree. As a result, sclerotic 
changes occur with atrophy of the nerve fibres. 

. The interference with function will depend upon the ex- 
tent of the lesion, and the possibility of restoring the parts to 
a normal condition will depend upon the same fact. The 
condition is characterized by an interference with the percep- 
tion of the middle notes of the musical scale, the tone limits 
remaining normal. Bone conduction is not destroyed com- 
pletely, although it is much diminished. The galvanic irrita- 
bility of the nerve is usually increased. 

The treatment should be directed toward the improve- 
ment of the general condition of the patient. Mental and 
physical rest should be secured. The food should be of the 
most nourishing quality, while the general neurasthenic con- 
dition should be combated by the administration of strych- 
nine. After the acute symptoms have subsided, this drug 
should be given in large doses, to secure its well-known spe- 
cific effect upon the nerve tissues. 

Epidemic Cerebro-spinal Meningitis. 

Pathology. — In scarlet fever, diphtheria, measles, mumps, 
typhus and typhoid fever, variola, epidemic influenza, etc., the 
primary invasion of the labyrinth occurs by direct infection 
through the blood current. When the meninges are invaded 
by the specific germ of the disease under consideration, the 
inflammatory process extends along the lymph channels of the 
vestibular and cochlear aqueducts, and involves the structures 
located within the bony labyrinth. During the early stages 
both the perilymph and endolymph are increased in quantity, 
while at the same time their composition undergoes a change 

39 



578 THE EFFECT OF ACUTE INFECTIOUS DISEASES. 

through the action of the specific germ. Later, the bony 
walls are the seat of inflammatory changes. Both the ar- 
teries and veins become dilated. There is a migration of 
white blood cells into the surrounding tissues, and true tissue 
hypertrophy takes place. From the extensive proliferation 
of the blood vessels themselves in the newly deposited tissue, 
the walls of these channels are of unusual tenuity and rupture 
easily. Hence extravasation of blood constitutes one of the 
conditions found. The newly deposited tissue increases in 
density, and may be transformed into bone, in which case the 
semicircular canals or cochlea are partially or completely 
obliterated. In other portions the chief force of the disease 
expends itself in tissue necrosis ; the labyrinthine channels 
being filled with pus. Occasionally the tympanum is invaded 
secondarily by a rupture of the membrane at the round or 
oval windows, allowing the inflammatory products to escape 
into the middle ear. From the tympanic involvement the 
drum membrane is soon destroyed, and a purulent otorrhcea 
manifests itself. Naturally this condition is somewhat rare, 
as death usually takes place before sufficient time has elapsed 
for its completion. 

Symptomatology. — In addition to the symptoms charac- 
teristic of meningeal inflammation, we have vertigo, sudden 
loss of hearing, and intense tinnitus. In very young chil- 
dren the vertigo may be the only evident symptom, on ac- 
count of the age of the patient. Occurring in older indi- 
viduals, the access of subjective noises is usually sudden, 
while their intensity is so great as to be agonizing. The 
hearing is either completely destroyed at once, or this con- 
dition occurs at the end of a few hours after the appearance 
of the symptoms. Preceding these marked evidences of laby- 
rinthine invasion, the power of audition may be abnormally 
acute, probably from the hyperasmic condition of the laby- 
rinthine structures. This hyperacusis may be so marked that 
faint sounds even are painful, the patient starting at the slight- 
est noise, and complaining of an increase in the headache 
characteristic of meningitis. After a short time the subjective 
noises diminish, owing to the destruction of the terminal fila- 
ments of the eighth nerve, and the hearing remains pro- 
foundly impaired for the same reason. The power of equi- 
librium gradually returns, although this is more slow, per- 
haps, than the disappearance of the subjective noises. The 



DIAGNOSIS— PROGNOSIS. 



579 



involvement of the middle ear is evidenced by the ordinary 
symptoms of an acute purulent inflammation arising from 
any other cause. 

Diagnosis. — A. PJiysical examination is of importance in 
that it yields absolutely negative results, the membrana tym- 
pani and meatus presenting a normal appearance. From the 
absence of any deviation from the standard of health, togeth- 
er with the presence of subjective symptoms referable to the 
ears, suspicion is naturally directed toward the nervous ap- 
paratus. 

Functional Examination. — B. Impairment of hearing, both 
for sharp sounds and speech, is either profound or the patient 
is absolutely deaf. If any power of audition remains, it is 
usually for the low notes of the scale, the higher notes not 
being heard at all. Rare exceptions are found where the 
apex of the cochlea is first involved. This, however, occurs 
but seldom ; in fact, the lower notes of the scale may be heard 
with abnormal clearness during the stage of hypersemia on 
account of the hyperaesthetic condition of the nerve. Bone 
conduction is greatly diminished, and after a few hours is 
absolutely lost. It may be completely absent, although the 
ear may still perceive sounds by aerial conduction. 

Prognosis. — If the patient recovers from the meningeal 
inflammation the outlook for the preservation of hearing is 
exceedingly grave. In severe cases absolute deafness results, 
while in the milder instances a certain amount of audition 
may be preserved. The disappearance of the subjective 
noises is a rather unfavorable symptom, since it denotes com- 
plete ansesthesia of the auditory nerve or perceptive centres, 
and often absolute destruction of the terminal nerve filaments. 
The involvement of the labyrinth in no way affects the prog- 
nosis as regards life. This disease is of particular moment 
when met with in very early life, since the loss of the audi- 
tory perception renders the patient mute as well as deaf. 
This is true even if the child has learned to talk fairly well, 
such words as have been learned being forgotten. In older 
children mutism may not follow, since the association between 
written and spoken words is sufficient to preserve the power 
of speech. The effect of treatment is usually unsatisfactory 
in the severe cases, although in the less severe cases, where a 
certain amount of hearing has been preserved, the function of 
the organ may be still further improved. 



580 THE EFFECT OF ACUTE INFECTIOUS DISEASES. 

Treatment. — But little can be done to prevent the exten- 
sion of the meningeal inflammation to the labyrinth. With 
the development of the hyperacusis it is wise to apply cold 
locally to the mastoid process, while at the same time free 
bloodletting is advisable, provided the general condition of 
the patient will admit of this. Free catharsis should also be 
obtained if the general condition does not contraindicate it. 
If our efforts are unsuccessful, nothing can be done until the 
acute symptoms have subsided, after which the reduction of 
labyrinthine pressure by the use of pilocarpine, either ad- 
ministered hypodermically or by the mouth, is always advis- 
able, and is frequently followed by favorable results. This 
is true, although the patient may not present for treatment 
until a considerable period after the attack of meningitis, and 
where a careful examination seems to indicate that even a 
small portion of the cochlea has escaped destruction, the util- 
ity of the organ can usually be improved. In addition to the 
pilocarpine, strychnine in large doses is an agent of consider- 
able value in preventing a rapid degeneration of the nerve 
fibres in the trunk, from the changes which have taken place 
in the labyrinth. When the acute symptoms have completely 
subsided, exercise of the organ, either through the agency of 
the human voice — a conversation tube being used, if necessary 
— or by the employment of some instrument based upon the 
principle of the phonograph, may still further improve the 
hearing. It is to be specially remembered that both dynamic 
and therapeutic measures must be continued for a long period 
in order to be of the least value, and any slight gain is to be 
looked upon as encouraging. It is wise, in case pilocarpine 
is to be administered for a long period, to occasionally stop 
it altogether for an interval of one to three weeks, after which 
it is to be resumed, beginning with small doses. The general 
condition of the patient must always be kept as near normal 
as possible, and all conditions are to be avoided which disturb 
the labyrinthine circulation either directly or indirectly. 



CHAPTER XXXVIII. 

INVOLVEMENT OF THE PERCEPTIVE MECHANISM IN ACUTE 

MENINGITIS. 

Pathology. — Meningitis of the nonepidemic type may pro- 
duce secondary changes in the labyrinth in the same manner 
as the epidemic form of the disease. A traumatic meningitis 
is usually localized, and consequently the labyrinthine in- 
volvement is unilateral as a rule. In addition to direct exten- 
sion through the labyrinthine aqueducts, the function of audi- 
tion may be interfered with either by direct pressure of the 
products of inflammation upon the auditory nerve trunk, or 
by the involvement of the nerve sheath itself in the process, 
or by a localized meningitis over the cortical auditory area. 
When the labyrinth is the seat of the lesion, the process differs 
from that met with in the epidemic variety of the disease, in 
that it is less extensive and seldom leads to the complete de- 
struction of the parts within the bony capsule. Pressure 
upon the nerve trunk causes degeneration of the nerve fibres 
according to well-known physiological laws, but seldom 
causes a destruction of all the fibres of the trunk. A cortical 
lesion presents essentially the same characteristics in that the 
entire sensory area is seldom destroyed. 

An idiopathic meningitis interferes with the auditory 
function in the same manner, the exact pathological process 
depending upon the location of the intracranial lesion. 

Symptomatology. — The symptoms will vary according to 
the particular location of the meningeal inflammation. Where 
direct extension to the labyrinth occurs, subjective noises of 
varying intensity, moderate or severe vertigo, and a varying 
degree of impairment of hearing are present. The severity 
of each of these symptoms will depend upon the extent to 
which the labyrinth is invaded. Where the trunk of the 
nerve is attacked the same conditions are present, although 
here the auditory impairment is the prominent symptom, and 
is usually most pronounced for the middle notes of the scale, 

(581) 



582 THE PERCEPTIVE MECHANISM IN ACUTE MENINGITIS. 

perception for high and low notes being fairly well preserved. 
In either case the impairment of function is unilateral, the 
opposite organ remaining perfectly healthy. 

Meningitis over the convexity of the brain involving the 
cortical perceptive area interferes with the function of both 
ears, the defect being most marked upon the side opposite to 
the cortical area involved. 

If the affection is labyrinthine there is but little tendency 
to an increase in the symptoms, but rather to a spontaneous 
retrogression. Where the nerve trunk or the cortical cen- 
tres are the parts primarily involved, the symptoms increase 
or diminish according as the meningitis becomes more dif- 
fuse or yields to appropriate therapeutic agents. In trau- 
matic cases the area affected may be so located as to cause 
an interference with equilibrium alone, the hearing remain- 
ing intact, while tinnitus is absent. Another symptom quite 
characteristic is the development of hyperacusis or dysacusis, 
this latter symptom corresponding to the familiar ocular 
disturbance, photophobia, so characteristic of meningeal in- 
flammation. 

Lesions involving the cortical areas, or the paths of com- 
munication within the brain ' itself, produce the quite char- 
acteristic symptom of word deafness ; the sound is heard but 
is not interpreted, or, if interpreted, is recognized imperfectly 
or slowly. A somewhat similar condition presents when the 
trunk of the nerve is involved, on account of the interference 
with the middle portion of the musical scale. As this por- 
tion of the register is the one ordinarily employed in conver- 
sational speech, the power of interpreting language is some- 
what perverted, especially when the conversation is general. 
Complete deafness for any particular word or combination 
of sounds does not exist, however, but simply impairment. 
Again, as we shall see, the complete functional examination 
of the case enables us to distinguish with considerable ex- 
actness between the two conditions. While a labyrinthine 
lesion in the early stages is characterized by distressing tin- 
nitus, any inflammation of the meninges which causes either 
pressure upon the nerve or upon the cortical perceptive area 
does not, as a rule, present this characteristic. Where pres- 
sure is exerted upon the trunk of the nerve, atrophy takes 
place quite early ; hence any noise which may have been 
present in the incipient stage may disappear ; and the same 



DIAGNOSIS— FUNCTIONAL EXAMINATION. 583 

is true where the lesion is cortical. The future progress of 
the case will depend upon the intracranial changes present. 
In traumatic meningitis the disappearance of the acute local 
lesion will either be followed by a rapid decrease in the 
symptoms if the products of the inflammation are absorbed, 
or the condition may remain permanent, there being no tend- 
ency to progression. This is true of those cases where 
either an epidural or cerebral abscess does not follow. If 
either of these conditions is present the symptoms increase 
as the localized collection of pus becomes augmented in 
volume. 

Diagnosis. — Our diagnosis will depend upon the history 
either of a traumatism, or, in idiopathic cases, of symptoms 
characteristic of meningeal inflammation. Examination by 
means of the speculum will reveal the parts in a normal con- 
dition, or, in the case of injury to the head, there may be evi- 
dences of rupture of the membrana ty mpani ; and it must be 
borne in mind that when these signs are present there is 
more difficulty in determining the actual condition of the 
perceptive apparatus on account of the tympanic complica- 
tion. When no middle-ear lesion exists, a determination of 
the exact portion of the perceptive tract involved depends 
entirely upon the functional examination and upon the ante- 
cedent history. 

Functional Examination. — Where the lesion is labyrinthine, 
the lower tone limit is usually normal, the upper tone limit 
much lowered, bone conduction very slight or absent, while 
the impairment of hearing for the conversational voice is 
relatively less than that for high-pitched sounds. If the lesion 
is so extensive as to cause impairment for the conversational 
voice, this is seldom of a moderate degree, but the deafness is 
almost absolute. Paracusis Willisii is absent. Artificial aids 
to hearing do not improve the auditory power, and the pa- 
tient becomes greatly fatigued after attempting to exert the 
power of audition for any considerable period, the hearing 
becoming rapidly worse, and evidences of severe mental exer- 
tion manifest themselves. The reaction to the galvanic cur- 
rent reveals usually a condition of marked hyperassthesia 
when the lesion is recent. In cases of long standing this con- 
dition may be replaced by one of torpidity. When the trunk 
of the nerve is pressed upon, the upper and lower tone limits 
vary but little from normal. The notes of the middle register 



584 THE PERCEPTIVE MECHANISM IN ACUTE MENINGITIS. 

are poorly heard, and bone conduction is either absent or 
diminished to a marked extent. In testing bone conduction 
in these cases several tuning forks of different pitch should be 
used, since the nerve may react perfectly to forks of one 
pitch while it does not respond to others. The electrical re- 
action shows a persistent hypersesthetic condition, the degree 
of hyperesthesia varying but little on succeeding days, and 
being replaced by one of torpidity in the late stages only. 

When the cortical centre is implicated the presence of tone 
gaps is a characteristic symptom. The most certain evidence 
of involvement of the cortical area, however, is the appearance 
of word deafness. The patient hears isolated sounds, and 
even spoken words, but finds it impossible to repeat spoken 
words or to correctly interpret their meaning. Naturally the 
lesion is bilateral, although the impairment is more marked 
upon the side opposite the involved area. Bone" conduction 
in these cases is diminished, but seldom absent on account of 
decussation of the fibres. The tone gaps may be present in 
any portion of the scale. The galvanic current may reveal 
hyperaesthesia or some other deviation from the normal stand- 
ard, such as a reversal of the normal reaction formula, or a 
paradoxical reaction. This latter term is used to designate 
the condition in which stimulation of the organ of one side 
produces phenomena on the opposite side. The concomitant 
symptoms ordinarily are sufficiently marked to confirm the 
diagnosis in cases where cortical involvement is suspected. 

Prognosis. — If we exclude meningitis due to abscess and 
intracranial tumors, the process is not progressive in cases 
where the lesion remains intracranial. In the same manner, 
although to a less degree, an extension to the labyrinth sel- 
dom presents this tendency, the process being limited to the 
immediate area first involved. 

In rendering an opinion, therefore, we may confidently 
state that the hearing will improve rather than diminish as 
age advances. 

Treatment. — In the acute stage our measures of treatment 
are confined to those directed toward meningeal inflamma- 
tion. After the acute stage is past, if the lesion is laby- 
rinthine, the administration of pilocarpine hastens the absorp- 
tion of the effusion within the labyrinth, and causes a rapid 
improvement in function provided complete destruction has 
not taken place. From the well-known action of the iodide 



TREATMENT. 585 

of potassium on recent inflammatory exudates it is well to 
combine this drug with the "pilocarpine in moderate doses. 
Where the lesion is intracranial, the administration of iodide 
of potassium for a considerable period in moderate doses is 
probably the best means at our command. Coincident with 
this we may give strychnine in the form of the sulphate or 
nitrate, beginning with small doses and increasing the amount 
to the point of tolerance. It must be remembered that the 
administration of strychnine should not be begun until all 
acute symptoms have disappeared. In cases of intracranial 
involvement the careful and systematic use of some apparatus 
designed to moderately stimulate the auditory nerve by so- 
norous vibrations is of undoubted value. The particular de- 
vice is of but little importance, and may vary from a simple 
conversation tube to a more complicated instrument. It is 
important that the stimulation of the nerve in this manner 
shall not be carried too far, as, where it is too prolonged, the 
function of the nerve is blunted rather than preserved. 



CHAPTER XXXIX. 

THE EFFECT OF DISEASES OF THE GENERAL NERVOUS 
SYSTEM UPON THE PERCEPTIVE MECHANISM. 

We have already considered the result of the acute in- 
flammatory conditions met with in the meninges, and there 
remains for discussion those affections which are character- 
ized by degenerative changes in the various parts of the 
brain. These are cerebral congestion, apoplexy, cerebral em- 
bolism, endarteritis, cerebral tumors, disseminated sclerosis, 
and tabes dorsalis. From the location of the cortical audi- 
tory centres, and the fact that each auditory centre receives 
fibres from the labyrinth of either side, any cortical lesion must 
be bilateral and extensive to produce absolute deafness upon 
either side. The crossing of the auditory fibres takes place in 
the medulla in the region of the olivary bodies, and an intra- 
cranial lesion upon one side could only produce total deaf- 
ness in one ear when situated between the foramen of exit of 
the auditory nerve and the corresponding olivary body. A 
tumor at the base of the skull might possibly produce this 
effect, but we find that neoplasms seldom occur in this region. 

Investigation of cases of cerebral haemorrhage and of em- 
bolism show that in comparatively few instances is the organ 
of hearing affected to a perceptible degree. Even if the cen- 
tre upon one side is largely destroyed, its place is supplied by 
the corresponding area in the opposite cerebral hemisphere, 
and the impairment in function is but slight. 

The symptom most characteristic of a cortical lesion is 
known as " word deafness." Here words are heard but not 
understood, the patient simply obtaining the general impres- 
sion of sound without being able to interpret it. A subjec- 
tive symptom characteristic of the cortical involvement is 
the presence of certain complex auditory impressions or hal- 
lucinations. The patient seems to hear voices, the conversa- 
tion either being directed to him, or he may simply be the 
listener. Among musicians these hallucinations may assume 

(586) 



CORTICAL LESIONS— TABES. 



587 



the character of well-known musical selections performed by 
an orchestra. The sufferer is able to follow each instrument 
as it performs its special part, and is frequently tormented by 
the impression that one or more is slightly out of tune. The 
exact pathological condition in the cortex exerts but little in- 
fluence upon the symptoms, and may be either congestive, 
hemorrhagic, degenerative, sclerotic, or neoplastic. Transi- 
tory subjective disturbances of this character are probably 
due to either cerebral congestion or anaemia. The possibil- 
ity of locating a pathological process within the brain itself 
depends upon the presence of associated nervous symptoms 
due to the coincident involvement of contiguous areas, while 
at the same time an examination of the ear reveals the con- 
ducting mechanism to be in nearly a normal condition. 

In tabes dorsalis the changes which have been recognized 
consist in an extension of the sclerotic process to the auditory 
nerve itself, or to its centres. It is characteristic of all affec- 
tions of the acoustic nerve trunk that the electric excitability 
is increased until degenerative changes are so far advanced 
that the function of the ear is entirely lost. A permanent 
hyperaesthesia of the nerve, therefore, is strongly indicative 
of intracranial disease if peripheral irritation can be excluded 
in the given case. The portion of the musical scale most 
affected is usually the middle notes of the register, the upper 
and lower tone limits being normal. Where the cortical 
areas are involved the same rryperaesthesia may be met with. 
As distinguished from labyrinthine lesion, any change in 
labyrinthine pressure brought about by artificial means, such 
as inflation of the tympanum, will exert but little influence 
upon the perception of sound through the bones of the skull. 
In labyrinthine disease, the disturbance from labyrinthine 
pressure brought about in this way usually diminishes bone 
conduction. It is also to be remembered that until a high 
degree of atrophy has been reached bone conduction is pre- 
served when the symptoms are due to an intracranial growth.* 

In discussing the symptoms in the previous pages we 
have confined ourselves to the hypothesis that the intra- 
cranial process was confined to the cerebrum. When the 
cerebellum is involved, disturbance of equilibrium occurs, to- 
gether with nausea, while there may be no impairment in the 

* Politzer, Diseases of the Ear, American edition, p. 587. 



588 EFFECT OF DISEASES OF THE NERVOUS SYSTEM. 

hearing. Changes in the trunk of the nerve may give rise to 
disturbances of equilibrium, as well as to subjective noises 
and impairment of hearing. 

Practically the diagnosis in these cases depends more 
upon the associated symptoms characteristic of the general 
nervous affection than upon the aural manifestations. The 
absence of any evident condition within either the conduct- 
ing mechanism or labyrinth which is capable of producing 
the symptoms, while at the same time the evidence of the 
general nervous affection is marked, is the chief aid to diag- 
nosis. 

Regarding medication but little can be said. The chief 
indications for treatment will be furnished by the general 
nervous disease. If the aural symptoms are pronounced, 
they should be treated according to the directions already 
given. For the subjective noises the bromides will usually be 
found most efficacious. If there are evidences of faulty nutri- 
tion of the nerve tissue, strychnine in large doses will often be 
of benefit in preventing the total loss of function. From the 
possibility of a specific taint large doses of the iodide of po- 
tassium should be given in any case if there is evidence of 
intracranial involvement. 



SECTION V. 

COMPLICATING AURAL DISEASES. 



COMPLICATING AURAL DISEASES. 



CHAPTER XL. 

AURAL AFFECTIONS COMPLICATING THE ACUTE INFECTIOUS 

DISEASES. 

We have already considered the changes which may take 
place in the perceptive portion of the auditory mechanism 
from the acute infectious diseases. In addition to these, the 
conducting apparatus is a frequent site of pathological condi- 
tions from the same cause. In a majority of cases the acute 
infectious disease produces an inflammation of the middle ear 
when this organ of special sense is in any way involved. It 
may be stated, as a general rule, that the severity of the inflam- 
mation within the tympanum corresponds in degree to that of 
the exciting cause. Thus, in the milder exanthemata — such as 
measles, varicella, mild influenza, and in mumps — an affection 
of the middle ear is usually confined to the lower portion of the 
cavity, constituting either a tubal catarrh or an acute catar- 
rhal otitis media. If rupture of the drum membrane takes 
place, the discharge is serous or sero-mucous in character, 
and only becomes purulent by infection from without. In the 
more severe infectious diseases — such as severe cases of rubeola, 
scarlatina, variola, typhus fever, and diphtheria — the infection 
is more virulent, and here the connective-tissue structures are 
the chief seat of involvement. In other words, the otitis 
media, which complicates the diseases just named, has its 
origin in the upper portion of the tympanic cavity, and con- 
stitutes in reality a cellulitis. This cellulitis follows the course 
typical of such a process in any portion of the body, and very 
quickly results in extensive tissue necrosis, the soft structures 
breaking down with the formation of pus, while after a com- 
paratively short interval the contiguous bony structures be- 
come affected and rapidly disorganize. It is probable that in 

(591) 



592 COMPLICATIONS OF ACUTE INFECTIOUS DISEASES. 

a given case the selection of the lower or upper portion of the 
tympanic cavity as the seat of process depends entirely upon 
the degree of infection rather than upon the selection of any 
particular region by various organisms, the lower portion 
being involved in the milder cases, while the upper part is 
attacked in the more severe forms of infectious disease. Bac- 
teriological investigation goes to show that the germ charac- 
teristic of the particular disease is not so much the cause of 
the otitis media as are the bacteria of suppuration, and that 
the number of these last-named germs present depends en- 
tirely upon the degree of systemic infection. 

It may seem that this line is rather sharply drawn, as 
many cases present in which at first it is almost impossible to 
reconcile clinical experience with this theory. A careful study 
of many cases has convinced me that where these anatomical 
boundaries are transgressed this departure is always marked 
by a corresponding change in the general symptoms of the 
patient. Thus in epidemic influenza of a mild type, or in a 
mild case of measles, we should expect the lower portion of 
the tympanum to be involved, the characteristic signs being a 
comparatively slight amount of pain in the ear, of short dura- 
tion, and quickly followed by the effusion of serum or sero- 
mucus. Where the quantity of fluid is not sufficient to cause 
rupture of the membrana tympani the fluid may remain in the 
middle ear for a considerable length of time. During this 
period the temperature will remain moderately elevated, or 
may reach normal if the process is entirely quiescent. Sud- 
denly the temperature rises rapidly, the patient exhibits con- 
siderable prostration, and the pain in the ear returns. An 
examination will now reveal that, in addition to the effusion 
already present in the lower portion of the tympanic cavity, 
there are unmistakable evidences of involvement of the vault. 
The fluid in the middle ear is a culture medium which favors 
the development of pathological bacteria, and if these are still 
present, invasion of the upper portion of the cavity may take 
place at any time. In the same manner those cases where 
the process at first seems confined to the upper portion of the 
cavity, but does not go on and rupture through Shrapnell's 
membrane, may remain quiescent for several days, the tem- 
perature becoming normal and the pain in the ear disap- 
pear, although the local manifestations, such as redness above 
the short process and above the anterior and posterior liga- 



SYMPTOMATOLOGY. 



593 



ments, still continues. A sudden rise of temperature, with 
pain in the affected organ, is accompanied by a bulging- of the 
entire posterior quadrant, and a rapid extension of the redness 
to the region of the membrana vibrans. Here the products of 
inflammation have passed into the atrium, following the long 
process of the incus ; and the involvement of the atrium is to 
be looked upon as a secondary infection, giving rise to distinct 
symptoms. It is scarcely necessary to call to mind the clinical 
importance of the facts already stated when we remember 
that any inflammation in the upper portion of the tympanic 
cavity always constitutes a disease of considerable gravity, 
and one which demands prompt measures for its relief, while 
an inflammation of the atrium is comparatively simple if we 
can confine it to this region. According, then, as our gen- 
eral disease is mild or severe, we may predict with consider- 
able certainty a corresponding degree of aural involvement. 
The exact method of dealing with these conditions has already 
been sufficiently dilated upon. 



40 



CHAPTER XLI. 

AURAL AFFECTIONS DEPENDENT UPON CHRONIC VISCERAL 

CONDITIONS. 

In general, we may state that any changes within the vis- 
cera produce disturbances referable to the ear chiefly from 
their effect upon the general venous circulation. Where the 
venous flow through the larger viscera is obstructed, a dam- 
ming back of the return current from the internal ear results, 
leading in time to a dilatation of the venous channels within 
the auditory apparatus. This is particularly true of the laby- 
rinth, and, as already mentioned, constitutes a common cause 
of labyrinthine congestion. Within the middle ear or within 
the meatus corresponding changes may occur, as evidenced 
by an increased vascularity in the parts and a greater tor- 
tuosity of the minute veins. 

Nephritis. 

In nephritis, the pathological conditions found in the organ 
of hearing depend both upon the obstruction to the general 
venous circulation and also upon that condition of the arteries 
so frequently met with, known as arterio-capillary fibrosis. 
As the result of these changes within the vessel walls, the tis- 
sues are poorly supplied with blood, the result being that the 
entire economy is in a condition below the normal standard 
of health. The quality of the blood circulating within the 
vessels is also impoverished, its fluid elements being relatively 
increased. 

Within the tympanum these changes in the vessels and in 
the quality of the blood frequently result in a transudation 
of serum through the vessel walls, the lesion being similar to 
that of pleural effusion in nephritis. This condition should 
not be looked upon as an inflammation, although it is fre- 
quently called otitis media serosa. The process is entirely 

(594) 



NEPHRITIS— METASTASIS. 



595 



mechanical, and the fluid is the result of transudation, and 
not of an inflammation. The fluid within the cavity may be 
absorbed spontaneously, or may remain for an indefinite pe- 
riod. When the middle ear is in this condition it is more 
liable to become the seat of a mild catarrhal inflammation 
than under normal conditions. Coincident with the effusion 
there is usually a partial or complete stenosis of the Eusta- 
chian tube, due to passive congestion of the lining membrane, 
with a diminution of atmospheric pressure within the middle 
ear. This change favors the passage of fluid from the blood 
vessels into the tympanic cavity, and the process tends to effect 
permanent changes. From the weakness of the vessel walls 
rupture is not uncommon, and hasmorrhagic otitis media, or, 
more properly, hasmato- tympanum, is occasionally found. 
These hasmorrhages ma) 7 also occur in the external auditor} 7 
canal, or between the layers of the drum membrane itself. 
Similar changes may take place within the labyrinth, in one 
case causing an increase in labyrinthine pressure either by an 
augmentation in the quantity of perilymph or by actual haem- 
orrhage into the labyrinthine channels. In the latter instances 
the extravasation of blood may destroy the end organ of the 
auditory nerve over a given area, rendering it useless and inca- 
pable of performing its function. This will lead to absolute 
deafness to the particular sound which this portion of the 
cochlea perceived. Hasmorrhagic changes in the sheath of 
the auditory nerve may also complicate a chronic nephritis. 
The blood supply of the labyrinth is derived from several 
channels, and hence the occlusion of one of these efferent 
vessels might take place without seriously impairing the func- 
tion of the part, the blood supply being maintained through 
the collateral circulation. 

Metastasis. 

An extensive suppurative process in any portion of the 
body, such as an acute osteomyelitis or bony caries, or necro- 
sis located in any region, may be the point of origin of infec- 
tious emboli. These are carried through the various circula- 
tory channels, either into the middle ear or labyrinth, and 
their lodgment produces symptoms dependent upon the shut- 
ting off of the blood supply of the parts beyond, or by a local- 
ized secondary infectious process which they excite. It is 
not improbable that chronic suppuration within the accessory 



596 COMPLICATIONS OF CHRONIC VISCERAL LESIONS. 

sinuses of the nasal cavity is responsible for many obscure 
aural symptoms met with in these cases. The entrance of an 
embolus into the blood current from one of the accessory si- 
nuses, and its subsequent passage into the labyrinthine vessels, 
is the most plausible explanation of the cases of mild tinnitus 
and sudden impairment of hearing of moderate degree which 
are frequently met with. In ulcerative endocarditis, an in- 
fection either of the internal, middle, or external ear may 
take place in the same manner, from a detachment of the vege- 
tations on the cardiac valves. 

In acute pulmonary affections, particularly pneumonia, an 
acute middle-ear inflammation may result from the passage 
of the infectious germ through the blood current and its 
lodgment in the tympanic mucous membrane. It is probable 
that certain cases are due to the entrance of germs through 
the Eustachian tube. The degree to which the middle ear is 
involved will depend upon the severity of the pulmonary 
process ; if this is severe, the aural inflammation will be sup- 
purative, while in the milder cases it is a simple catarrhal 
inflammation, or may cease spontaneously at the stage of con- 
gestion. 

Tuberculosis. 

In tuberculosis, the involvement of the middle ear is char- 
acterized by the insidious manner in which the infection de- 
velops, frequently the first symptom which the patient recog- 
nizes being discharge from the ear, there having been no 
pain or noticeable impairment of hearing previous to this 
time. On examination, the entire drum membrane may be 
wanting, and in some cases the ossicula themselves may have 
become involved. Where the destruction of the membrane 
has taken place over a limited area the perforation presents 
a somewhat characteristic appearance. It is usually circular, 
the edges are thick and everted, and present, instead of the 
bright-red color commonly observed in a simple perforation 
of the membrana tympani, a blue-white, glossy, cedematous 
appearance comparable to that seen over the arytenoid car- 
tilages in laryngeal tuberculosis. Another condition which 
is somewhat characteristic is the appearance of two or more 
distinct perforations in the membrane. Where the ossicles 
are involved, the surrounding bony structures are quickly 
attacked, and the entire mastoid may be broken down even 



TUBERCULOSIS— LEUCAEMIA. 



597 



at a very early period. It is important to recognize the dis- 
ease in its incipiency, as prompt removal of the affected parts 
may check the progress and relieve to a degree the sys- 
temic condition dependent upon it. Usually, when the organ 
of hearing is attacked, the pulmonary or visceral involvement 
is an affair of so much greater gravity than the aural affec- 
tion as to make this latter insignificant. If, from the severity 
of the symptoms, or in the hope of stopping the progress 
of the affection it is deemed advisable to attack the local 
lesion, we should remember that any operative measures will 
be greatly aided by the administration of those drugs which 
seem to exert a specific influence upon the tubercular pro- 
cess. 

The nutrition of the patient should be particularly at- 
tended to. Cod-liver oil, the hypophosphites, and the vari- 
ous preparations of malt are all of value in the various cases, 
and much is to be said in favor of the administration of creo- 
sote in doses of one half to three grains three or four times 
daily. While I do not wish it to be understood that the tym- 
panic lesion demands treatment in a large majority of cases, 
or that radical treatment directed to this part is advisable, it 
is well to bear in mind the possibility of systemic infection 
from this focus, and also the fact that the local process is sure 
to extend rapidly, and is hence more easily checked in its 
early stage than after it has existed for a considerable period. 

Leucaemia. 

In leucaemia a form of deafness is found depending upon 
the passage of minute cells or lymph corpuscles into the laby- 
rinthine channels (Fig. 152), narrowing their calibre and in 
time even leading to a complete obliteration of their lumen. 
In the early stages this deposit is cellular in structure ; but if 
the patient survives the disease fo.r a long time, organization 
of this tissue may take place, and the obliteration of the laby- 
rinthine passages is effected by an osseous deposit, the symp- 
toms depending upon the extent of the local process and upon 
its severity. It is recognized by the presence of the gen- 
eral leucsemic condition, and with the sudden appearance of 
deafness which gradually grows worse, together with vertigo, 
nausea, and subjective noises. The functional examination 
reveals a lesion of sound-perceiving apparatus rather than one 



598 COMPLICATIONS OF CHRONIC VISCERAL LESIONS. 

referable to those parts concerned in sound transmission. 
Practically nothing can be done to stay the progress of the 
affection, our efforts at treatment being as futile as those em- 
ployed to combat the constitutional affection. 








if ; "': : :-- 



Z<M 



■ 



JS.T 



FlG. 152. — Section through the middle turn of the cochlea in a case of leucaemia, 
showing infiltration. (Gradenigo.*) 0, Bone ; S. V., Scala vestibuli ; S. T., 
Scala tympani ; L. S., Ligamentum spiralis; A.V., Stria vascularis; N.F.^ 
Nerve expansion in the lamina spiralis ; e, /, g, Membrana tectoria ; h, Inner 
hair-cells ; m, n, Corti's rods ; a, /, d, Limbus lamina spiralis ; /, Epithelium of 
sulcus spiralis internus ; /, Epithelium of sulcus spiralis externus ; C. £., Outer 
cells of Corti and Deiter ; c, c, /, Claudius's cells. 



* Arch, fur Ohrenheilk., vol. xxiii, p. 242. 



DIABETES— GOUT— RHEUMATISM. 



599 



Diabetes. 

In severe cases of diabetes the most characteristic affec- 
tion referable to the ear is the occurrence of acute circum- 
scribed external otitis. When we remember how prone the 
diabetic patient is to furunculosis, we can explain the occur- 
rence of the aural lesion upon the same ground. Eczema of 
the auricle and canal is also of common occurrence. Within 
the tympanum there is scarcely any condition characteristic 
of diabetes, although it is probable that all structures, includ- 
ing those of the middle ear, are more liable to attacks of in- 
flammation than under normal conditions. Symptoms refer- 
able to the sound-perceiving apparatus probably depend upon 
either labyrinthine haemorrhage or extravasation into the me- 
dullary or cortical centres. The repair of any lesion sponta- 
neously is slow in these cases. When the condition is an 
acute inflammatory one, suppuration is the rule. This is 
worthy of note where the mastoid process becomes involved 
consecutive to an inflammation within the canal or middle 
ear. Often, in spite of the greatest precaution, prolonged 
suppuration occurs ; and while we should not be deterred 
from operating upon diabetic patients for this reason, efforts 
to secure perfect asepsis must be vigorously enforced. 

Gout and Rheumatism. 

Gout and rheumatism probably exert a greater influence 
upon the organ of hearing than is usually supposed. It is 
not necessary that the patient shall have ever been the victim 
of an acute gouty or rheumatic attack, the hereditary diathet- 
ic condition being sufficient to induce pathological changes 
within the ear. While the cases dependent upon gout or 
rheumatism as the sole cause are probably rare, any acute or 
chronic inflammatory process arising from some other cause 
is modified to a marked degree through these diatheses. 
Thus in numerous cases of nonsuppurative otitis media our 
measures for relief may be without result until internal medi- 
cation is directed toward the correction of the gouty or rheu- 
matic taint. In the canal itself a persistent eczema rather 
mild in character is frequently met with in patients suffering 
from a gouty diathesis. Although in itself this inflammation 
would scarcely attract the attention of the patient, it leads to 
a condition of the cutaneous lining of the canal which favors 



600 COMPLICATIONS OF CHRONIC VISCERAL LESIONS. 

the development of vegetable parasites. When these have 
once gained lodgment in the meatus, the local inflammation 
which they excite by their presence is sufficient to produce 
marked symptoms from which the patient seeks relief. 

Treatment of the local condition will probably be without 
avail unless the gouty diathesis is at the same time borne 
in mind and combated. In the tympanum itself we find in 
rare instances an inflammation of the interossicular articula- 
tions which is probably rheumatic in nature. The local ap- 
pearances are confined to the immediate region of the articu- 
lation. The pain is severe, the constitutional disturbance 
marked and out of proportion to the local lesion, and efforts 
to afford relief are unsuccessful until antirheumatic drugs are 
administered. The symptoms abate under this plan of medi- 
cation, and the disease follows the course of an acute articu- 
lar rheumatism of any of the larger joints. It was formerly 
supposed that the gouty diathesis exerted a peculiar influence 
upon the development of exostoses within the bony meatus, 
but this theory has not been borne out by subsequent investi- 
gation. Of much more importance is the influence which 
this diathetic condition exerts upon the walls of the blood 
vessels. Arterial degeneration takes place, the vessels be- 
coming rigid through the deposit of lime salts in their walls, 
thus narrowing the calibre and so weakening the walls that 
they are easily ruptured by any sudden increase in blood 
pressure. These effects are most marked within the labyrinth, 
and give rise to subjective noises, giddiness, and slight im- 
pairment in hearing. In advanced cases the occurrence of 
capillary haemorrhages also serves to explain many of the 
symptoms met with. 

Medicinal Substances. 

The ingestion of certain medicinal substances exerts a 
specific influence upon the organ of hearing. Of these, the 
most prominent is quinine. Salicin, salicylic acid and its 
salts exert a similar influence in a less degree. In general 
these changes constitute in mild cases a congestion both of 
the middle ear and of the labyrinthine structures. When any 
drugs of this character are administered in excessive doses 
this hyperemia may lead to rupture of the vessels, causing 
minute haemorrhages. When administered for a long period, 
even in moderate doses, the chronic congestion produces 



MEDICINAL SUBSTANCES. 601 

structural changes particularly within the labyrinth, which 
do not disappear even after the administration of the drug is 
stopped. When the ear is in a normal condition it is probable 
that serious injury following the exhibition of these drugs is 
comparatively rare ; but where the ear is the seat of a chronic 
inflammatory process, or is particularly susceptible to cir- 
culatory changes, their use is to be guarded against. It is 
manifestly impossible to prevent the use of these remedies in 
all cases of chronic aural disease, but they should never be 
given except in an extremity, and then should be exhibited 
in small doses, and discontinued as soon as possible. The 
habit of prescribing large doses of quinine for a cold in the 
head can not be too strongly prohibited. 

The moderate use of tobacco influences the organ of hear- 
ing but slightly, whether the parts are in a state of health or 
disease. It was formerly supposed that its use aggravated 
any pre-existing catarrhal inflammation of the upper air tract, 
and in this way aggravated chronic affections of the tym- 
panum. The danger in the use of tobacco does not lie in 
this direction, but rather in the effect which the drug exerts 
upon the general nervous system. If the habitual use of to- 
bacco produces constitutional disturbances referable to the 
general nervous system, there is no question about the advis- 
ability of stopping it at once. That it should exert any spe- 
cific action upon the organ of hearing, while the general 
nervous organism escapes, is exceedingly improbable. We 
may practically disregard any action upon the conducting 
mechanism ; and if the receptive portion of the auditory sys- 
tem suffers from its habitual use. we shall have confirmatory 
evidence from its effect upon other portions of the nervous 
system. The particular region of the perceptive tract af- 
fected is probably either the nerve trunks or centres them- 
selves. " 



CHAPTER XLII. 

DISTURBANCES OF AUDITION DEPENDENT UPON FUNCTIONAL 
NERVOUS DISORDERS. 

The most common functional disturbances of the nervous 
system which produce any marked effect upon the organ of 
hearing are those known under the terms ''neurasthenia" 
and " hysteria." 

Since the exact nature of these conditions is at present 
problematical, the manner in which they influence the vari- 
ous portions of the sound-perceiving mechanism is a mat- 
ter of conjecture. In certain instances neurasthenic or hys- 
terical patients will present marked disturbances referable to 
the organ of hearing. These disturbances probably depend 
upon some slight pre-existing pathological condition which 
ordinarily would pass unnoticed. The lesion may lie either 
in the meatus or in the tympanic cavity, and be entirely un- 
recognizable upon careful examination ; but as it constitutes 
the point of least resistance in the nervous system, the mani- 
festation of a neurasthenic or hysterical condition is exhibited 
here rather than in another locality. The reason for believing 
this, is that where a moderate affection of the sound-conduct- 
ing mechanism exists, the disturbance of function is out of all 
proportion to the pathological condition present; and in addi- 
tion to these symptoms, w T hich are characteristic of involve- 
ment of the transmitting apparatus, certain other manifesta- 
tions present which can only be explained by the abnormal 
general condition. 

Neurasthenia. 

In neurasthenia the entire nervous system seems to be 
overtaxed by even a moderate effort ; and where the function 
of any one organ is impaired, as in the cases under considera- 
tion — the organ of hearing — this impairment is magnified to a 
great degree. In general these cases are characterized by 
the symptom which may be termed "auditory strain." In 

(602) 



NEURASTHENIA. 603 

conversation with one individual the patient hears fairly well, 
and the hearing is usually better early in the morning. After 
being subjected to the fatigue consequent upon the day's ac- 
tivity, the hearing power becomes' much diminished, and any 
effort on the part of the patient to disguise the symptom 
simply magnifies it. The local impairment, in turn, reacts 
upon the general condition of the patient to a considerable 
degree, frequently causing him to become hypochondriac, 
and in some cases leading to acute melancholia. The hearing 
is more impaired in a noisy than in a quiet room ; tinnitus is 
present, and varies greatly in degree, being more marked 
when the patient is tired. In addition to these subjective symp- 
toms, certain others manifest themselves, such as a feeling of 
formication in the canal ; a feeling of occlusion in the meatus, as 
though a foreign body were present ; or a sensation of irritation 
referred either to the Eustachian orifice or to the base of the 
tongue. Often during the process of examination the hear- 
ing fluctuates greatly. If patients can be convinced that no 
test is being made, they frequently respond to questions 
asked in a moderate tone of voice ; as soon, however, as they 
become aware that the power of audition is being estimated 
their anxiety to hear causes a marked diminution in the 
power. 

Diagnosis. — As said before, certain deviations from the 
normal standard may be found upon speculum examination, 
or these departures from the normal may be so slight as to 
be entirely overlooked. Functional examination is a matter 
of considerable difficulty, especially if any recognized lesion 
of the conducting apparatus is present, the answers of the pa- 
tient being very misleading unless the general condition is 
borne in mind. As a rule, low tones are well heard, the low- 
est limit of the scale being frequently preserved, even where 
inspection shows a marked alteration in the conducting 
mechanism. The upper tone limit may be moderately low- 
ered, but is occasionally elevated, and the high notes may be 
painful. Bone conduction is diminished, while sharp sounds, 
such as the tick of a watch or the click of the acoumeter, give 
varying results, being heard at one time exceedingly well, at 
another time poorly or not at all. The voice is usually heard 
better relatively than either the watch or acoumeter. 

The most valuable aid in diagnosis is a comparison of 
the results obtained by functional examination with the gen- 



604 INFLUENCE OF FUNCTIONAL NERVOUS DISEASES. 

eral history of the case. When we consider the undue im- 
portance which these patients attach to the slight subjective 
symptoms of which they complain — referable to the meatus, 
the vault of the pharynx, or region oi the Eustachian tube 
— we can readily understand why the results of functional 
examination should be so at variance with what might be 
expected. 

The hyperacusis which is quite commonly observed in 
these cases explains the preservation of the lower tone limit 
even when this should be considerably elevated. We are 
apt to be misled also by this symptom, for quantitative 
tests may yield entirely negative results, the patient hear- 
ing the watch, acoumeter, or whispered speech at the normal 
distance. Continuing the examination for some time, we 
shall usually find that the organ soon becomes tired and the 
hearing power rapidly diminishes. This fatigue manifests 
itself not only for any one sound, but when this condition is 
reached all sounds are poorly perceived. This, we must re- 
member, is a marked deviation from the normal standard. 
In health, although the sonorous vibrations of any given 
pitch will, after a time, so fatigue the perceptive centres as 
to reduce the power of audition for that particular sound, 
yet this impairment of function does not invariably occur 
with the perception of sounds of different pitch, but rather 
renders the hearing of them more acute. In order to test 
the ease with which the ear is fatigued it is only necessary 
to make use of a tuning fork of 512 V. S., or the octave 
above this, and maintain the fork in vibration close to the ear 
for a period of five to ten minutes, setting it in vibration 
anew as soon as its note becomes weak. If the fork is struck 
with approximately equal force each time, it will be found 
that the period during which its vibrations are perceived will 
become shorter and shorter. In some cases we find that the 
ear very quickly ceases to perceive the note of the fork. If 
now the instrument is removed from the ear for a few sec- 
onds, and then again brought immediately in front of the 
meatus, the note will again be heard, although the instru- 
ment has not been set in vibration afresh, and hence the 
sound is less intense than when it was removed from in front 
of the ear. This is called a secondary perception of the note. 
In marked instances we find even tertiary or quaternary 
perceptions. This phenomenon corroborates the statement 



TREATMENT OF NEURASTHENIA— HYSTERIA. 605 

of the patient that the power of audition is poorest in listen- 
ing to general conversation. 

Prognosis. — Aside from any organic changes which may 
be present either in the middle ear or labyrinth, the prog- 
nosis will depend upon our ability to control the general 
nervous condition. This is difficult, and the outcome of such 
a case must always be uncertain. If the patient can be per- 
suaded to think less about his hearing, there is fair hope that 
the power of audition will improve. 

Treatment. — No drugs exert a specific action upon the 
central portion of the auditory apparatus in this condition, 
and the treatment of defective hearing will resolve itself into 
the treatment of neurasthenia. Strychnine in large doses, as a 
nerve tonic, is of use in a considerable proportion of cases. 
Where the strychnine increases the excitability of the pa- 
tient, this may be controlled by the administration of bro- 
mide of sodium in proper doses at the same time. We thus 
overcome the reflex excitability produced by the first drug, 
while we in no way diminish its action as a nerve tonic and 
as a stimulant to the nervous centres. A complete change 
of scene is advisable, and where the disease has resulted 
from prolonged mental exertion it is well to interdict work 
of this kind. This is by no means an absolute rule, as a con- 
siderable proportion of patients do not improve unless their 
minds are occupied in some manner. A complete change of 
occupation is desirable in these cases, since they may become 
so interested in their work as to forget themselves, and thus 
second our efforts in restoring their normal condition. 

Hysteria. 

This affection is closely allied to the one just described, 
and frequently accompanies it. Why, in a given case of hys- 
teria, symptoms referable to the ear are paramount, can be 
explained only on the ground already given in considering 
the effects of neurasthenia — that in these cases the ear is the 
point of least resistance. 

Symptomatology. — Impairment in hearing varies greatly 
in degree, but is usually profound, and the patient may be 
completely deaf. The deafness comes on suddenly, as a rule, 
quite frequently as the result of some severe mental shock, 
and possesses the peculiar characteristic of preserving the 
original degree of impairment throughout the entire history 



606 INFLUENCE OF FUNCTIONAL NERVOUS DISEASES. 

of the case. The condition neither improves gradually nor 
does it grow worse. Complete restoration of function may 
take place from no assignable cause, and may occur quite as 
suddenly as the power of hearing disappeared. 

Another curious symptom is the so-called transference of 
the lesion from one side to the other. For a certain length 
of time the organ of one side alone will seem to be perfectly 
deaf. Suddenly the hearing will be restored upon this side, 
but at the same time the organ of the opposite side becomes 
affected. This change may be repeated any number of times. 
Pain is quite commonly complained of in the region of the 
ear, it being located either deep in the meatus or in the mas- 
toid process. Occasionally this pain is referred to the phar- 
yngeal vault, although this is not common. Giddiness and 
subjective noises are usually absent, the case thus presenting 
a marked contrast from one dependent upon neurasthenia. 
Where other symptoms of a hysterical nature are present, 
such as hemiansesthesia or hemiplegia, the defective ear is 
usually on the side of the body presenting the sensory or 
motor impairment, although this is not invariable. 

Diagnosis. — The above phenomena may be observed where 
to all appearances the organ is perfectly healthy, or we may 
find, upon examination, evidences of a preceding suppurative 
or nonsuppurative process. The eye alone aids us very little 
in making a correct diagnosis. Much information, however, 
may be obtained by testing the sensitiveness of the meatus 
and drum membrane by means of the probe, the parts being 
quite frequently anaesthetic. Functional examination, also, 
may reveal nothing characteristic, although in quite a num- 
ber of cases we find that both the upper and lower limits of 
the scale are poorly perceived, the lower tone limit being 
elevated, while interference with the upper tone limit seems 
to be more common than with the lower, the high notes be- 
ing but poorly heard, as a rule. This reduction of the upper 
tone limit is distinct, usually extending as low as 4 or 6 of the 
Galton scale. 

A symptom frequently met with in an examination is the 
alternating perception of the high notes first on one side and 
then on the other. Upon one side the upper tone limit 
will be found greatly reduced, while the organ of the oppo- 
site side will perceive the highest tones of the scale with 
ease. On repeating the experiment, the condition will be 



HYSTERIA— PROGNOSIS— TREATMENT. 607 

exactly reversed, and this alternation may be repeated several 
times during the examination. 

The occurrence of other hysterical manifestations affords 
confirmatory evidence. This is particularly true if the field 
of vision is investigated, since in most cases this is uniformly 
contracted. 

Prognosis. — It is absolutely impossible in a given case to 
render an intelligent opinion as to the recovery of the hearing. 
It is a well-known fact that in hysteria many of the symptoms 
may completely disappear, while the others remain unabated ; 
and we also note that interference with any special sense is a 
symptom which does not disappear readily. 

Treatment. — Those drugs administered for the control of 
hysteria are indicated in these cases. Valerian, either in the 
form of the simple tincture or the ammoniated tincture, is 
often of value. The same is true of asafcetida, the bromides, 
various preparations of zinc, phosphorus, hyoscyamus, galba- 
num, etc. 

Hypnotic treatment is probably of more value in these 
cases than any other, and is always worthy of a trial. It 
should never be forgotten that hysteria is a disease, and that 
the patient is not malingering ; hence severe measures are 
worse than useless. Curious instances have been reported 
of the complete disappearance of the deafness upon bringing 
a magnet close to the ear. By this same means it has also 
been possible to transfer the condition to the opposite side. 



CHAPTER XLIII. 

REFLEX AURAL DISTURBANCES. 

A PATHOLOGICAL condition in any portion of the body 
may produce within the organ of hearing, not only alterations 
of function, but also certain visible changes. While we are 
familiar with the precise mechanism by which motor reflexes 
are brought about, those of a sensory or trophic character are 
as yet obscure. The most plausible view is, that under the 
reflex stimulus certain changes take place in the vascular sup- 
ply of the part affected, through the action of the vasomotor 
nerves, and that capillary dilatation is responsible for the phe- 
nomena produced. In the conducting portion of the organ of 
hearing the deviations from the normal standard are of such 
a nature as to be visible to the eye, while in the nervous ap- 
paratus subjective symptoms are the only indication of any 
change from the standard of health. Changes which take 
place in the auricle from reflex action may cause an abnormal 
redness or congestion of the part ; or, if the capillaries are 
constricted, the blood supply will be diminished, the ear ap- 
pearing pale and bloodless. When the trophic nerves are in- 
terfered with, a cutaneous eruption may occur, the most com- 
mon of which is herpes, the auricle being covered by small 
vesicles at first discrete, but by coalescence forming bullse. 
The symptoms have already been described by herpes of the 
auricle. 

Within the canal a circumscribed external otitis may de- 
pend upon a reflex cause, the pathological lesion producing it 
being most frequently a corresponding condition upon the 
opposite side. Hypersensitive areas may also develop in the 
meatus, usually in the bony portion and upon its floor, the 
region being excessively tender to the touch of the probe, 
while ocular inspection either reveals no deviation from the 
normal condition, or only a minute erosion at the tender point. 
In some instances periodical attacks of bleeding from the 

(608) 



TYMPANUM-PERCEPTIVE MECHANISM. 



609 



meatus occur, depending upon changes in some remote organ 
of the body. 

Within the tympanum a reflex stimulus may cause a tran- 
sudation either of blood or serum ; in either case the quan- 
tity of fluid may be so great as to cause rupture of the mem- 
brana tympani. Instances of otitis media of a reflex character 
have also been observed. Pain in or about the ear in a vast 
majority of cases depends upon some local inflammatory pro- 
cess. It is occasionally met with where no inflammatory pro- 
cess presents upon the most careful examination. In children 
particularly, a reflex otalgia often occurs, depending either 
upon the eruption of the molars or upon early dental caries. 
This latter condition is occasionally the cause of an inflamma- 
tory affection of the middle ear, either acute or chronic. A 
symptom of rare occurrence is a periodical oedema over the 
mastoid process, accompanied by exquisite pain and tender- 
ness. I have observed one instance of this in which acute 
middle-ear inflammation was complicated by this angioneurotic 
oedema ; considerable difficulty was experienced in arriving at 
a correct diagnosis, and the question of the advisability of open- 
ing the mastoid was seriously debated. All reflex disturb- 
ances, particularly those of a painful character, are most fre- 
quently met with in females of a neurotic or hysterical type. 

When we come to consider the perceptive tract, cases of 
anaesthesia or paresthesia are by no means uncommon. A 
moderate impairment of hearing may be the result of visceral 
disturbances, particularly of the pelvic viscera, while tinnitus 
resulting from constipation, subacute gastritis, a pathological 
condition within the pelvis, etc., is of common occurrence. 
An interference with the statical function of the ear is proba- 
bly the most familiar example of reflex excitation of the 
auditory perceptive apparatus. The giddiness so common in 
disorders of digestion is without doubt dependent upon 
stimuli conveyed to the auditory nucleus in the medulla 
through the vagus nerve, the vagus centre lying close to the 
nucleus of the vestibular nerve. It is probable that here the 
condition is one of increased vascularity from capillary dilata- 
tion. Reasoning in this manner, we are able to explain irreg- 
ular attacks of impairment in the hearing of short duration, 
accompanied by intense subjective noises, by supposing that 
a similar disturbance has taken place either in the medullary 
centre of the cochlear nerve or in the cortical auditory cen- 
41 



610 REFLEX AURAL DISTURBANCES. 

tre itself. The symptom which leads us to suspect that any 
functional disturbance of the ear is dependent upon a reflex 
cause is the irregular appearance of the symptoms, and their 
sudden and complete subsidence, often from no apparent 
cause. Structural changes necessitate a certain permanency 
of the manifestation ; and where this does not occur we can 
only explain the condition by supposing that the centres have 
been irritated by a temporary increase in the blood supply. 

If now a thorough examination of the patient reveals a re- 
mote lesion, particularly if it is located in a region where or- 
ganic changes are prone to excite reflex symptoms, we should 
bear in mind that such reflex symptoms may be quite as well 
referred to the organ of hearing as to any other portion of the 
body. We can not too strongly emphasize the necessity of a 
thorough physical examination in every obscure case ; in other 
words, the otologist should locate subjective phenomena in 
the ear rather by exclusion than otherwise. 

We have already spoken of those regions of the body where 
any specific change is particularly liable to exert a reflex in- 
fluence upon either the centres of audition or the terminal 
apparatus of the auditory nerve. To this list we must add the 
opposite ear, since lesions of an inflammatory character, or in- 
juries to the organ of one side, may produce not only tempo- 
rary but often permanent changes in the opposite organ. 
The augmentation of the perceptive power observed when 
the opposite organ of hearing is subjected to sonorous vi- 
brations has already been alluded to. Another familiar ex- 
ample is the effect of condensing the air in the auditory 
meatus, while at the same time a sounding body is held close 
to the opposite ear. If this experiment is tried, we find that 
the sudden condensation of air diminishes the perceptive 
power of the opposite organ. Here it is supposed that the 
path of the reflex current lies through the upper portion of 
the cervical cord, and the test is used to demonstrate the 
integrity of this portion of the central nervous system. The 
experiment is of much greater value from a clinical point of 
view in explaining the occurrence of subjective noises re- 
ferred to one side, in which an examination of the ear reveals 
nothing abnormal. Examination of the opposite side fre- 
quently reveals either a narrowing of the Eustachian canal, 
the presence of impacted cerumen, or a marked pathological 
process within the tympanum, and the subjective symptoms 



DIAGNOSIS— PROGNOSIS— TREATMENT. 6l I 

do not disappear until the pathological condition in the op- 
posite ear is removed. 

Diagnosis. — The recognition of the reflex nature of these 
symptoms then depends upon their occurrence in an appar- 
ently healthy organ, and next upon the discovery of some 
remote pathological condition which may act as an exciting 
cause. A valuable confirmatory sign is that afforded by an 
examination with the galvanic current, a condition of marked 
hyperaesthesia usually being found. If we can exclude with 
certainty an active process within the middle ear or within 
the cranium itself, the auditory hyperaesthesia must be reflex ; 
and if the cause does not lie in the opposite ear a remote lesion 
alone can explain it. 

Prognosis. — Our ability to correct these reflex disturb- 
ances depends not only upon the amenability of the primary 
exciting cause to treatment, but also upon the duration of the 
affection before the patient comes under observation. The 
persistent excitation of the perceptive centres directly, or in- 
directly through the end organ of the nerve, may effect changes 
which will remain after the exciting cause has been removed. 
Where the case is observed early and depends upon a re- 
movable cause, the results of treatment are, as a rule, favorable. 

Treatment. — Our first object when a case of this character 
presents for treatment is to relieve the aural symptoms from 
which the patient is suffering, without reference to the causa- 
tion. Unless this cause is manifest, much valuable time is 
wasted in searching for the ^etiological feature. The percep- 
tive tract is in a state of constant hyperaesthesia, which from 
its long duration may be difficult to overcome after the excit- 
ing cause has disappeared. Undoubtedly the drug which ex- 
erts the most influence in these cases is bromide of sodium, or 
its equivalent, hydrobromic acid. By the administration of 
these remedies the receptive centres are rendered less sensi- 
tive to the action of stimuli. The effect is similar to that ob- 
tained when a broken limb or strained joint is placed in a 
fixation apparatus ; the nervous tissues are put completely at 
rest, so to speak, by rendering them insensible to the action 
of the stimulus. Our next effort should be to discover the 
cause of the affection ; this can only be done by a thorough 
investigation of the history of the case — not only the history 
of the disease, but one calculated to elicit all facts of medical 
or surgical interest throughout the entire course of the pa- 



612 REFLEX AURAL DISTURBANCES. 

tient's life. An injury received in childhood and entirely for- 
gotten may have set in play forces, which in adult years have 
produced the symptoms complained of. The age of the pa- 
tient is to be borne in mind, particularly in the case of females, 
since the period about the menopause is a time at which these 
symptoms are particularly prone to make their appearance. 
The habit of life, the occupation, and all facts which may 
directly or indirectly exert an influence upon the nervous 
tone of the body, should be carefully investigated. Several 
factors may present as a possible cause of the aural disturb- 
ance, and time is necessary for the thorough elimination of 
the unimportant ones. It should always be borne in mind 
that these cases are among the most troublesome that we 
have to treat, and may for a long time be irresponsive to all 
our efforts. It is only by the process of exclusion that the 
exact ^etiological feature can be discovered, after which its 
correction is usually a matter of comparative simplicity. 

Diathetic conditions, particularly gout and rheumatism, 
may have manifested themselves previously in no other man- 
ner, and the symptoms referable to the organ of hearing may 
be the first intimation of the presence of such conditions. The 
history of heredity in such a case is the only clew to guide us 
to the discovery of the cause operative in the production of 
symptoms. 

Where bromides fail to control the reflex phenomena, hy- 
oscyamus, either in the form of the tincture or in the form of 
the alkaloid — hyoscyamine — may serve an efficient purpose. 
Under no circumstances should morphine be administered, 
since it is easy for the patient to acquire the opium habit if 
this practice is once begun. The various antispasmodics, 
such as asafcetida, valerian, galbanum, etc., are of use in cer- 
tain cases, and indications for their administration are usually 
sufficiently clear. Where the symptoms have persisted for a 
long time and there are evidences of vascular dilatation, the 
fluid extract of ergot, in doses of fifteen to twenty minims, 
three times daily, exerts a beneficial action. 

Symptoms of venous congestion dependent upon imperfect 
cardiac action demand the use of stimulants. Of these, strych- 
nine is probably the best, provided no organic lesion is pres- 
ent. If the disturbance of circulation is only moderate, the 
use of a certain amount of an alcoholic stimulant daily is a 
valuable means of effecting the desired change. In asthenic 



TREATMENT. 



613 



cases, particularly where the patient has suffered from over- 
work, the addition of a moderate amount of wine to the 
dietary is followed frequently by happy results ; the desired 
stimulating result is thus obtained without resorting to the 
administration of drugs. In cases where anaemia is coinci- 
dent, naturally this condition must be treated on general 
medical principles; and the same is true of the management 
of those cases where there is a plethoric intracranial con- 
dition. 



CHAPTER XLIV. 

DEAF-MUTISM. 

The loss of audition in the early years of life, or the ab- 
sence of this special sense as a congenital defect, invariably 
leads to mutism. It is manifestly difficult to determine in 
many cases whether the power of sound perception has been 
destroyed by some disease in infancy or has been absent 
from birth. Practically the question is one of but little im- 
portance, as each case must present features peculiar to itself. 

^Etiology. — Heredity seems to play an important part in 
the causation of congenital deaf-mutism. Several members 
of the same family are frequently affected, although direct 
transmission is rather infrequent, the offspring of parents 
afflicted with the malady as a rule escaping. Consanguinity 
of the parents is among the most common of the causes, and 
the greater frequency of deaf-mutism among the inhabitants 
of mountainous districts is probably to be explained by the 
fact that intermarriage is much more common among such 
people. The station of life exerts very little influence upon 
the congenital form of the disease. Defective mental devel- 
opment is not, as a rule, associated with a congenital defect 
in audition, and in many suffering from the loss of this special 
sense the mental faculties seem to be developed beyond the 
normal standard. Hereditary specific disease is a causative 
factor in certain cases. 

Occasionally the affection seems attributable to influences 
during intra-uterine life, such as a severe mental shock to the 
mother, or some physical injury. 

Among the causes which lead to acquired deaf-mutism 
may be mentioned injuries to the head during labor or in 
early infancy ; the acute infectious diseases, leading to involve- 
ment of the perceptive tract, either primarily or as a result 
of a preceding middle-ear inflammation ; acute and chronic 
inflammatory conditions within the cranium ; adenoid vegeta- 

(6i 4 ) 



PATHOLOGY. 



615 



tions, causing a chronic congestion of the middle ear and 
labyrinth as well, the chronic hyperasmia of the middle ear 
leading to repeated attacks of acute catarrhal otitis in infancy. 
The precise manner in which the organ of hearing is affected 
in these diseases has already been dilated upon in the preced- 
ing chapters, and need not be repeated here. It is enough to 
remember that any affection of the conducting or perceiving 
mechanism which is sufficiently extensive to cause profound 
impairment of hearing will lead to deaf-mutism if it occurs 
in the early years of life, before the child has acquired the 
power of articulate speech. Even in children of four years of 
age, who can speak fairly well, the loss of the sense of hearing 
is often followed by mutism, the patients forgetting the few 
words which they have learned. This occurs almost invari- 
ably, unless special attention is directed toward its preven- 
tion. In older children the loss of audition is not necessarily 
followed by mutism. 

Pathology. — The congenital absence of some essential por- 
tion of the conducting mechanism has been found in a num- 
ber of cases which have been investigated post mortem. In 
speaking of deformities of the auricle, mention was made of 
the frequent absence of the bony meatus in those cases, and of 
the almost invariable malformation or absence of the deeper 
portions of the conducting mechanism in cases of congenital 
atresia of the canal. Acquired atresia of the meatus, if occur- 
ring in very early life, might also lead to deaf-mutism. Intra- 
tympanic changes preventing vibration of the labyrinthine 
fluid have also been found in certain instances. Occlusion 
of the round and oval windows, either as a congenital defor- 
mity or as the sequel to a pathological process in early life, 
constitutes the lesion in some cases. 

A congenital defect or an acquired lesion in the labyrinth, 
auditory nerve trunk, or in the nuclei of origin, fibres of com- 
munication, or cortical areas, constitute briefly the anatomical 
characteristics of cases resulting from interference with the 
perceptive mechanism. 

Among the secondary changes may be mentioned the 
lack of development in the vocal organs from prolonged dis- 
use. In cases presenting a lesion of the conducting mechan- 
ism sufficient to account for the absence of audition, it is 
probable that the changes in the perceptive tract may be due 
to the same cause. 



616 DEAF-MUTISM. 

Symptomatology. — In very young children who have 
never spoken, the first symptom noted is usually the failure 
to acquire the power of articulate speech. Attention is then 
directed to the ears, and it is discovered that the auditory 
sense is also wanting-. In older children, the failure to re- 
spond when spoken to and the gradual appearance of mutism 
declare the nature of the affection. In these older cases the 
hearing may not be entirely lost at first, and as the patient 
seems to hear loud sounds, parents often neglect the condi- 
tion until it is too late to prevent deaf-mutism. 

Diagnosis. — Since the age at which children acquire the 
power of articulate speech varies greatly, and as the same is 
true of the age at which the infant responds to stimulation of 
the organ of hearing, it is often difficult to determine whether 
or not a child is deaf or whether the development of the 
special sense is delayed simply. With a history of any pre- 
vious intracranial disease or any evidence upon ocular in- 
spection of an abnormity, congenital or acquired, of the organ 
of hearing there is naturally a strong suspicion that the con- 
ditions are interdependent. When the child has learned a few 
words and fails to advance, the diagnosis naturally presents 
no difficulties. It is certainly unsafe to give any other than a 
guarded prognosis in patients under eighteen months of age. 

Even very young children should be carefully tested as to 
their ability to perceive sounds varying in intensity and pitch. 
Tuning forks of low and high pitch furnish a convenient means 
of determining the probable presence of even a slight amount 
of audition. The forks should be set in vibration and held 
first before the ear, the attention of the child being diverted 
from the movements of the examiner. If the fork is heard, the 
little patient will usually give evidence of the fact, either by 
turning toward the source of sound, or there will be a change 
in facial expression which will be easily recognizable. If there 
is any doubt, the experiment may be repeated and the fork be 
held near the ear without being set in vibration. In the same 
manner bone conduction should be tested, the vibrating fork, 
and the same instrument in a state of rest being brought alter- 
nately in contact with the head. The Galton whistle should 
also be employed, and even in young children it is sometimes 
possible to obtain the limits of audition with fair accuracy. 

Clapping the hands behind the child's head, snapping the 
fingers, etc., are also tests which may be of use ; but my own 



PROGNOSIS— TREATMENT. 617 

experience has been that the tuning fork and Galton whistle 
will furnish the desired information. 

Prognosis. — This is necessarily grave. Politzer* consid- 
ers that the prognosis is better in the congenital than in the 
acquired cases. Certainly in those of congenital origin an 
unfavorable opinion should not be given in very early life, as 
the special senses may develop later. In the cases which 
follow any affection in early infancy, the nature of the disease 
which produced the aural affection, the extent of the local 
process, and the length of time which has elapsed before the 
patient comes under observation, all influence the prognosis. 

Treatment. — When the malady depends upon a known 
cause the indications for treatment will be clear. In all cases 
presenting a condition which could give rise to the profound 
impairment this should be removed. In young children the 
presence of adenoid vegetations should be determined, and if 
the drum membranes are intact any mass of this kind should 
be removed. In the same manner the history of an attack of 
epidemic cerebro-spinal meningitis or of an affection which 
could induce a labyrinthine inflammation should be an indi- 
cation for the use of the proper therapeutic measures. A 
thorough examination should always be made, but if no indi- 
cations are found for any particular plan of treatment, the sur- 
geon should remember that therapeutic measures are useless 
in many cases and that valuable time may be lost. If there is 
no indication for any one plan of treatment, the child should 
at once be placed in the hands of those who make the educa- 
tion of such patients a life study. It is rare in any case which 
comes under observation during childhood to find a com- 
plete absence of the auditory function, and by proper train- 
ing this may be much improved. The best results are ob- 
tained by those methods which stimulate the portion of the 
perceptive tract which remains by the use of the human 
voice, the sound being conveyed to the ear through a proper 
instrument, and by education render it capable of supplying 
the place of the perfect organ of hearing. It is surprising 
how much can be gained if these children come under ob- 
servation at an early period, and when we have decided that 
nothing can be done to relieve the condition it is our duty to 
urge their education in this manner. 

* Diseases of the Ear, American edition, 1894, p. 706. . 



DISEASES OF THE NOSE AND NASO-PHARYNX. 

It is necessary to consider, in connection with the ear, 
certain affections of the upper air passages which either have 
been operative in the production of the aural condition, or 
still exert a marked influence upon it. The principal affec- 
tions under this head will be considered brieflv, and more 
with reference to their treatment than to the special symp- 
toms which they produce. 

We may classify affections of the upper air passages which 
come under this head as hypertrophic and atrophic. The 
first condition interferes with the circulation within the tym- 
panum and labyrinth, and also disturbs the equilibrium of 
the drum membrane and ossicles by interfering with the 
free ventilation of the tympanic cavity. Atrophic changes, 
on the other hand, are much less frequently operative in the 
production of aural symptoms. Occasionally they represent 
the results of a previous inflammatory condition which has 
caused the aural affection, but, at the time when the atrophic 
changes are observed, exert but little influence upon the con- 
dition of the ear. The slight effect which they produce is 
mechanical, and depends upon the efforts of the patient in 
relieving the mucous membrane of accumulations of inspis- 
sated secretion dependent upon its atrophied condition. All 
these movements of the pharynx affect the calibre of the 
Eustachian tube and interfere with the atmospheric pressure 
within the tympanum. 

Anatomically we shall consider — 

i. Diseases of the nasal cavity. 

2. Diseases of the naso-pharynx. 

Under diseases of the nasal passages we have belonging 
to the group characterized by the presence of newly formed 
tissue, hypertrophic rhinitis and deformities of the nasal sep- 
tum. An atrophic condition of the mucous membrane lining 
the nasal cavity is more rare, and constitutes the disease 
known as atrophic rhinitis. 

■ (618) 






DISEASES OF THE NOSE AND NASO-PHARYNX. 619 

In the nasopharynx the most common hypertrophic con- 
dition is that known as adenoid vegetations, or enlargement 
of the pharyngeal tonsil. Neoplasms will not be considered 
here, since the aural symptoms to which they give rise are 
always secondary to those referred to the region from which 
the growth springs. An atrophic condition of the nasophar- 
yngeal mucous membrane constitutes the lesion in so-called 
naso-pharyngeal catarrh. 



CHAPTER XLV. 

HYPERTROPHIC RHINITIS. — DEFORMITIES OF THE NASAL 

SEPTUM. 

Hypertrophic Rhinitis. 

This condition consists in a true hypertrophy of the ele- 
ments which go to make up the turbinated bodies, and in- 
volves especially the inferior turbinated body. In addition 
to the new growth of connective tissue present, the venous 
sinuses inclosed between its meshes become tortuous, and 
increase in size and in number. As a result of these changes, 
the tissue covering the inferior turbinated bone is increased 
in volume, and in marked cases hangs loosely from its bony 
attachment, so as to obstruct the nostril to a considerable 
degree. When the venous channels are engorged with 
blood, this obstructing mass may attain such a size as to 
completely close the inferior meatus and prevent the passage 
of air. The condition probably depends most frequently, 
according to Bosworth, upon a deformity of the nasal sep- 
tum, and is most marked upon the side which is least ob- 
structed by the septal projection. Owing to the obstruction 
of the opposite nostril, each act of inspiration rarefies the air 
in the opposite nasal chamber and favors dilatation of the 
veins imbedded in the turbinated tissue. Continued for a 
long time, permanent tissue changes take place, resulting in 
the chronic venous engorgement, and in the hypertrophic 
tissue changes above enumerated. Such a condition renders 
the patient extremely susceptible to variations in temperature, 
which result in the affection commonly known as "cold in 
the head." Repeated attacks of this character operate to 
increase the chronic condition which underlies it. Without 
either entering into an enumeration of the various reflex dis- 
turbances depending upon this nasal condition, or dwelling 
upon the various local symptoms which are caused, we may 
state that the most common symptom of which the sufferer 

complains is the inability to breathe through the nose, and of 

(620) 



EFFECT OF OBSTRUCTIVE CONDITIONS. 62 1 

frequently repeated colds in the head. The effect of these 
attacks of nasal stenosis may influence the hearing to a 
marked degree. Patients almost invariably state that during 
such an attack the hearing is much less acute than when the 
nasal respiration is not interfered with, and that, as the at- 
tacks increase in frequency, complete restoration of the hear- 
ing does not take place as readily. The intervals during 
which the hearing is fairly good become shorter and shorter, 
until every fresh attack seems to leave the power of audition 
more impaired. While many of these symptoms depend 
upon interference both with the circulation within the tym- 
panum and the Eustachian tube, and with the proper ventila- 
tion of the middle ear, it is certain that a large proportion of 
cases are met with in which a physical examination reveals 
the Eustachian tube patent throughout the entire attack, and 
in these cases we must conclude that the turgescence of the 
turbinated bodies interferes with the venous return current 
from the labyrinth, causing labyrinthine congestion. Func- 
tional examination of these patients seems to confirm this 
view, and it is therefore important to remember that the 
venous engorgement within the nasal passages is operative 
in the production of labyrinthine symptoms directly, as well 
as in exciting changes in the tympanic cavity. 

This is undoubtedly the reason why, in many cases, sub- 
jective noises will be improved by treating the upper air pas- 
sages, although upon functional examination the patients 
exhibit none of the phenomena characteristic of an involve- 
ment of the conducting mechanism. The symptoms are, 
without doubt, due to vascular changes within the labyrinth 
dependent upon the turgescence of the turbinated tissue 
within the nasal cavity, and a removal of the cause relieves 
the symptoms. This fact certainly broadens the field of use- 
fulness of intranasal surgery, which has quite commonly been 
supposed to be of value only in affections of the middle ear. 
Symptoms referable to the nasal passages themselves have 
already been alluded to, while a more detailed account of the 
various aural symptoms will be found under the different 
diseases before described. 

Concerning the diagnosis of the condition, an examination 
both by anterior and posterior rhinoscopy will render its 
recognition easy. Upon anterior rhinoscopic examination, 
the inferior turbinated body will be seen to project into the 



622 HYPERTROPHIC RHINITIS. 

passage, occluding it more or less completely and preventing 
an inspection of the posterior wall of the pharyngeal vault 
through the anterior nares. Where a deformity of the sep- 
tum is present, the hypertrophy will be found more marked 
upon the side opposite to that occluded by the septal obstruc- 
tion. Curiously enough, the patient will complain of this 
nostril as the one obstructed, the reason being that respira- 
tion through the opposite passage having been imperfect for 
a long time, he has ceased to observe changes in its patency, 
while the obstruction upon the opposite side, or the one upon 
which he depends for nasal respiration, is immediately recog- 
nized, as an) T increased turgescence practically renders nasal 
respiration impossible. Impact with a probe temporarily ex- 
presses the blood from the swollen turbinated tissue, the 
engorged condition immediately recurring as soon as me- 
chanical pressure is removed. This examination with a 
probe also reveals to the operator that the membrane is 
thickened ; it feels velvety to the touch as the probe presses 
it against the outer bony wall of the nasal cavity. Posterior 
rhinoscopy will reveal a similar condition over the posterior 
extremity of the lower turbinated body, and in some instances 
the hypertrophic changes may be more marked here than an- 
teriorly. The posterior extremity of the inferior turbinated 
body may project into the cavity of the naso-pharynx as a 
round mass, completely occluding the choana of the affected 
side. Occasionally, instead of presenting a smooth contour, 
the surface of the mass is irregularly mammillated. This 
constitutes the so called posterior hypertrophy, and may be 
present upon both sides. 

The middle turbinated body may present evidences of 
hypertrophy, but less extensive usually than those exhibited 
by the inferior. 

If a ten-per-cent solution of cocaine is sprayed into the 
anterior nares, and the parts again examined after a few min- 
utes, a marked -change will be observed. Owing to the ac- 
tion of the drug, the venous engorgement will have disap- 
peared, the mucous membrane will be seen to apply itself 
more closely to the bony parts beneath, and the passage will 
be correspondingly more patent. The posterior pharyngeal 
wall will be readily seen in most instances, if the head of the 
patient is held in such a position that the floor of the nasal 
cavity is horizontal. In order to render this inspection of 



TREATMENT. 



623 



the posterior wall possible, the tip of the nose must be tilted 
up strongly, and the operator must so direct the rays of light 
that the deepest portion of the passage will be thoroughly 
illuminated. The light reflex of the posterior pharyngeal 
wall will then be seen, its recognition being more easy if the 
patient is asked to pronounce the letter k, thus elevating the 
soft palate. During this act the levator palati muscle will 
be seen to pass across the field of vision, encroaching upon 
the posterior nasal orifice. 

The results of treatment of this condition are exceedingly 
satisfactory, and it will be always possible not only to relieve 
the attacks of intermittent turgescence of the mucous mem- 
brane, but also to cause the absorption of hyperplastic tissue 
and to return the membrane to its normal condition. Our 
efforts at treatment must be directed both to the results of 
the hyperplastic process and toward the removal of those 
causes which operate to produce the intermittent turgescence 
of the membrane. 

If there is an obstruction upon one side due to a deform- 
ity of the nasal septum, this must first receive attention. 
The particular manner in which this shall be done will de- 
pend upon the choice of the individual operator, and some- 
what upon the character of the obstruction. Where a prom- 
inent ridge is present this is best removed by means of the 
nasal saw. Where the septal obstruction is not sufficiently 
circumscribed to admit of removal in this manner, it may be 
burned away by means of the galvano-cautery. Some prefer 
the use of the electric trephine, and good results undoubt- 
edly follow the use of this instrument, but the author has 
had no personal experience with it. For the relief of the 
turbinate hypertrophy the membrane should first be exsan- 
guinated by means of cocaine, after which a small bead of 
chromic acid melted upon the tip of a metal probe should be 
applied to a limited area over the inferior turbinated body. 
The site of the application should correspond to that which 
was most prominent before cocaine was applied. The super- 
ficial extent of this application will depend upon the degree 
of the previous turgescence ; usually the membrane is cov- 
ered with the chromic acid over an area about the size of a 
split pea. Care should be taken to dry the nasal mucous 
membrane with a pledget of cotton before applying the 
chromic acid ; any excess of acid is to be immediately re- 



624 DEFORMITIES OF THE NASAL SEPTUM. 

moved by means of a dry pledget of cotton, to prevent its 
spreading over the surface of the membrane. The result of 
this application is to form an inelastic eschar, which pre- 
vents the swelling of the turbinated tissue after the effect of 
the cocaine has passed away. The blood vessels are thus 
supported, and their walls resume their normal tone. The 
slough separates at the end of from five to ten days, after 
which the operation is repeated over another portion of the 
turbinated body. These applications are continued until the 
patency of the passage has been restored. When the hyper- 
trophy is excessive the cold wire snare may be used to re- 
move redundant portions. The membrane is first anaesthet- 
ized with cocaine and the loop made to surround the mass. 
The wire is then drawn into the tube and cuts through the 
tissue which it surrounds. When the mass is situated in the 
posterior nares the wire loop should be made to cut through 
slowly by using the screw. In this manner haemorrhage is 
avoided. As cocaine exsanguinates the membrane, it is well 
to use only a sufficient quantity to produce anaesthesia, in 
order that the snare may remove as much of the swollen mu- 
cous membrane as possible. After the operation is completed 
a little iodol is to be insufflated upon the cut surface, and the 
patient directed to avoid forcible efforts at clearing the nos- 
tril for at least twelve hours. In this way haemorrhage is 
avoided, and prompt recovery is the rule. 

Hygienic rules, such as proper attention to underwear, 
the daily use of the cold bath, etc., must not be forgotten in 
the treatment of these cases. 

Deformities of the Nasal Septum. 

As the condition which obstructive lesions of this char- 
acter produce have been discussed sufficiently under hyper- 
trophic rhinitis, we shall consider here only the surgical pro- 
cedures adopted for the relief of the obstruction. Where the 
deformity consists of a prominent ridge extending from the 
anterior portion of the cavity for a considerable distance 
toward the posterior nares, the nasal saw devised by Bos- 
worth seems to be the most simple instrument for relieving 
the condition. The patency of the passage is to be restored 
by sawing off the obstructing ledge either from above down- 
ward or from below upward, according to the special topog- 
raphy of the lesion and the choice of the operator. This 



TREATMENT. 625 

procedure can be carried out under cocaine anaesthesia, and 
is absolutely painless. Care should be taken that all instru- 
ments used at the operation have been previously sterilized 
by boiling- in a one-per-cent carbonate-of-soda solution. After 
the operation, a little iodol is insufflated into the passage, so 
as to cover the exposed surface, and recovery is usually un- 
eventful. 

Where the obstruction is of such a shape that the saw 
can not be used the galvano-cautery may be employed. After 
local anaesthesia has been induced by the use of cocaine, the 
flat platinum blade should be applied to the most prominent 
point and the obstruction burned away. The platinum tip 
should be at a bright-red heat, as a temperature below this 
causes pain, while if it is heated to a higher degree the opera- 
tion is likely to be followed by haemorrhage. It is usually 
unwise to attempt the destruction of a large obstructing mass 
at one sitting. A portion of the obstruction should be burned 
away, and the operation repeated at intervals of ten days or 
two weeks until a patent passage is obtained. The wounded 
surface is dressed in the same manner as when the saw is 
used. 



42 



CHAPTER XLVI. 

ATROPHIC RHINITIS. 

When the nasal passages are the seat of an atrophic 
process the mucous membrane covering the walls of the 
cavity becomes attenuated and applies itself closely to the 
underlying bony structures. Microscopical examination 
teaches us that this atrophy affects the glands with which 
the membrane is supplied. The secretion is altered in char- 
acter, and contains an excess of solid elements. The result 
is that it dries within the passage forming large irregular 
crusts upon the mucous membrane. As these crusts become 
dry they shrink, expelling the blood from the underlying 
mucosa, and mechanically augment the atrophic changes. 
Bosworth is undoubtedly correct in the statement that the 
disease is of long duration and develops as the result of puru- 
lent rhinitis in childhood, usually after one of the exanthe- 
mata. An examination shows an abnormal patency of the 
nasal passages, the membrane applying itself so closely to 
the bony framework that the turbinated bodies appear 
merely as lines upon the outer walls of the chambers. The 
post-pharyngeal wall can be easily recognized upon anterior 
rhinoscopic examination. Owing to the absence of the nor- 
mal turbinated tissue, the air which reaches the vault of the 
pharynx through the nasal cavity is not properly moistened 
and abstracts moisture from the membrane in this region ; 
the result is that we usually find a mass of inspissated mucus 
lining the vault of the pharynx. The patient complains not 
only of the crusts which are expelled from the nasal cavity, 
but also of the formation of a broad scale of tenacious mucus 
which is -drawn down from the vault of the pharynx after 
repeated efforts at clearing the passage. These masses of 
inspissated secretion within the nasal chambers undergo de- 
composition and frnpart to the breath an extremely fetid odor, 
which is a characteristic feature of the affection. 

The aural symptoms which are present in these cases are 

(626) 



PROGNOSIS— TREATMENT. 627 

ordinarily insignificant, and are usually due to a previous in- 
volvement of the middle ear in childhood, when the purulent 
rhinitis was at its height. It is possible that the imperfect 
moistening of the air may play a part in the production of 
certain aural symptoms, although this has never seemed to 
me probable. It is more likely that the condition within the 
middle ear is concomitant with rather than secondary to the 
nasal condition. 

The treatment of this affection is unsatisfactory as far as 
effecting a permanent cure, but efficient in relieving the pa- 
tient from the disagreeable symptoms which it causes. The 
first measure is to thoroughly cleanse the nasal cavity, remov- 
ing all decomposing crusts. This is best done by the- use of 
the nasal douche. At least a quart of a weak saline solution 
as hot as can be borne, is to be passed through the nasal 
chambers twice daily ; this not only washes away decompos- 
ing masses, but exercises a certain stimulating action upon 
the membranes. During the day the nasal chambers may be 
cleansed at frequent intervals with an alkaline spray such as 
the following: 

^ Sod. bicarb gr. xx ; 

Acid, boric 3 ss. ; 

Acid, carbolic rri . iv ; 

Glycerin 5 j ; 

Aqua q. s. ad § viij. 

M. Sig. : Dilute with an equal volume of water, and use 
in an atomizer as a nasal spray. 

Later, irrigation may be employed but once daily. If 
faithfully continued, this treatment will prevent the discom- 
fort attendant upon the nasal affection. The use of the nasal 
douche in these cases seldom produces aural symptoms, as 
the nasal passages are free and there is but little danger of 
the fluid entering the tympanum. It should always be re- 
membered in employing the douche that the current should 
enter by the occluded nostril if there is any difference in the 
patency of the two sides. In this way it is practically impos- 
sible for any accident to happen. The relief of the nasal con- 
dition exerts but little influence upon the aural disease. The 
chief source of relief is probably due to the fact that the 
patient makes less vigorous efforts at expelling the crusts by 
blowing the nose, and the sudden increase of tympanic pres- 



628 ATROPHIC RHINITIS. 

sure is thus avoided. In some instances it is wise to fur- 
ther stimulate the parts by the insufflation of the following 
powder immediately after the douche has been used: 

5 Pulv. sanguinarise 3 ss. ; 

Pulv. lycopodii q. s. ad g j. 

This causes considerable pain when insufflated into the nasal 
chambers and produces a profuse watery discharge. In this 
manner the turbinated tissues are stimulated to activity and 
return to a more nearly normal condition. The insufflation 
of the powder is to be discontinued after the tendency to 
crust formation has been checked. 



CHAPTER XLVII. 

ADENOID VEGETATIONS. 

This condition is undoubtedly responsible for more than 
half of the pathological lesions met with in the tympanum. 
It is essentially a disease of childhood, probably a manifesta- 
tion of a constitutional diathesis not inappropriately termed 
by Bosworth " lymphatism." The manner in which a mass 
of lymphatic tissue in the pharyngeal vault influences the 
organ of hearing has already been described in the beginning 
of this section, and need not be repeated. We should bear 
in mind that its influence is not alone confined to the middle 
ear, but that the vessels of the labyrinth undoubtedly suffer 
when this lymphatic tissue is the seat of repeated attacks of 
acute inflammation. 

The symptoms dependent upon the presence of the growth 
are those of nasal obstruction, the sufferer breathing almost 
entirely through the mouth, especially during sleep. The na- 
sal quality of the voice is wanting, and among young children 
there is a persistent discharge from the anterior nares. Such 
a growth becomes easily congested, and the cases present 
with the history of frequent colds in the head. A cold in the 
head in a child under twelve years of age is almost invariably 
dependent upon adenoid vegetations within the pharyngeal 
vault. 

The aural symptoms are quite as characteristic as those 
referable to the air passages. There are frequent attacks of 
earache, terminating in some cases in a discharge from the 
ear, which may continue as a purulent otitis media ; or where 
the inflammation is less severe there may be repeated attacks 
of tubo-tympanic congestion or of acute catarrhal otitis media 
without rupture of the drum membrane. In some instances 
the membrane is the seat of a minute rupture, and there is the 
history of slight serous discharge immediately following the 
attack, but disappearing spontaneously at the end of a few 

days. 

(629) 



630 ADENOID VEGETATIONS. 

The disturbances of function are also intermittent in char- 
acter. With every cold in the head the hearing becomes 
dull, and, if the patient is old enough to explain the symp- 
toms, he complains of a full or stuffy feeling in the ears, in 
addition to the impaired hearing. Many times this last symp- 
tom is misinterpreted in young subjects, and the child is con- 
sidered inattentive. Such a history should always lead to a 
careful examination of the ears, as most children who seem 
to be " absent-minded " are really hard of hearing. 

An examination of the oro-pharynx frequently shows that 
the faucial tonsils are enlarged, although they may be normal 
in size. Enlarged lymphatic nodules are frequently seen ir- 
regularly distributed upon the posterior pharyngeal wall, and 
are most numerous in the region of the posterior folds. Upon 
posterior rhinoscopy, the vault of the pharynx is seen to be 
occupied by a mass attached either to the roof or springing 
from the posterior wall. This mass may be most prominent 
in the median line, or the membrane covering the pharyngeal 
vault may be uniformly thickened, excepting in the region 
about the Eustachian orifices, where it is thrown into numer- 
ous folds and reduplications. The membrane covering the 
entire naso-pharyngeal space appears velvety and soft, resem- 
bling somewhat the faucial tonsils in appearance, although the 
tissue appears less firm. Where posterior rhinoscopy can 
not be conducted satisfactorily, such a growth may be seen 
by anterior rhinoscopy if the turbinated bodies have been 
previously exsanguinated by the application of a solution of 
cocaine. When this method is employed, the patient should 
sit so that the floor of the nasal chambers is very nearly in 
the horizontal plane. If the light is directed into the cavity, 
the adenoid growth will be seen lying behind the posterior na- 
sal opening, and sometimes encroaching upon it, if.it springs 
from the roof of the naso-pharynx. When attached to the 
posterior wall, it is recognized by the undue prominence of 
this region, while manipulation with a probe demonstrates its 
papillary character. 

In very young children either of these methods of exami- 
nation may be impossible. In such a case the mouth should 
be held open either with a mouth gag or by means of a cork 
inserted between the teeth, and the surgeon should pass the 
index finger behind the palate into the naso-pharynx ; the 
presence of the adenoid vegetations will be recognized by 



OPERATIVE TREATMENT. 631 

the soft, velvety feeling of the membrane. Upon withdraw- 
ing- the finger it will be usually found covered with blood, as 
in young children the soft tissue is easily wounded. 

The removal of such a mass is the only treatment to be 
considered if aural symptoms are present. The author's 
preference is the performance of a complete operation under 
general anaesthesia, the growth being removed by the forceps 
and curette. 

All instruments are to be sterilized by boiling. The child 
is placed upon the table in a recumbent position. For chil- 
dren under twelve years of age chloroform is without 
doubt the best anaesthetic to employ. After complete an- 
aesthesia the head is thrown backward over the edge of the 
table, or the same end can be attained by placing a small, 
hard pillow under the neck. By this procedure the vault of 
the pharynx is made to occupy a lower level than the larynx, 
and the danger of the accidental entrance of blood into the 
trachea is reduced to a minimum. The jaws are held apart 
by a properly constructed mouth gag, and the surgeon, stand- 
ing upon the right of the patient, introduces the left fore- 
finger behind the palate, where it remains until the operation 
is completed. The closed forceps held in the right hand is 
now passed along the left forefinger as a guide into the naso- 
pharynx, where it is opened and made to grasp as much 
of the growth as possible, the manipulation being directed 
by the left index finger. In this way the growth is removed 
piecemeal, and the operation is not considered complete until 
the examining finger fails to discover any masses projecting 
into the naso-pharyngeal space. The operation is completed 
by passing the curette into the space and sweeping it along 
each lateral wall and along the posterior wall of the cavity. 
The child is then turned over on the face, to facilitate the dis- 
charge of blood which has accumulated in the naso-pharynx 
during the progress of the operation, the mouth gag not be- 
ing removed until this position has been assumed. No after- 
treatment is necessary, and, if the instruments have been 
sterilized, recovery is uneventful. In rare cases the operation 
is followed by an acute congestion within the tympanum or 
by a catarrhal inflammation. This accident happens so sel- 
dom that it can be practically disregarded. Another com- 
plication which is perhaps more frequent is an acute follicular 
tonsillitis, but this is also very rare. 



632 ADENOID VEGETATIONS. 

Intimately associated with enlargement of the pharyngeal 
tonsil is a similar condition affecting the lymphatic tissue 
of the oro-pharynx. Many years ago the removal of en- 
larged faucial tonsils for the relief of impaired hearing was 
advocated by Yearsley. After Meyer had shown the marked 
effect whieh hypertrophy of the pharyngeal tonsil exerted in 
the causation of inflammatory processes within the tympanum, 
removal of the faucial tonsils for these conditions fell into dis- 
use. It is probable that excision of the faucial tonsils is de- 
manded in many cases of aural disease both of the suppura- 
tive and of the nonsuppurative variety. It is also probable 
that the beneficial effect produced is due largely to the ab- 
sorption of the pharyngeal tonsil which follows the operation 
in many cases. As a rule, however, whenever the faucial 
tonsils are hypertrophied, and at the same time an inflam- 
matory process is present within the tympanum, their re- 
moval should be advocated. In the large majority of cases 
enlarged faucial tonsils occur coincidently with an enlarged 
pharyngeal tonsil, and should be removed at the same time 
that the operation is performed upon the adenoid vegetations. 

In subjects under the age of twelve, tonsillotomy is best 
performed by any one of the various instruments which have 
been devised for this purpose. The author prefers Mathieu's 
instrument, but any of the others are probably equally efficient 
in expert hands. 

When tonsillotomy and the removal of adenoid vegeta- 
tions are practiced at the same operation, it is usually wise to 
remove the faucial tonsils first, as the haemorrhage from the 
pharyngeal vault rather obscures the field of operation if the 
adenoid growth is first attacked. 



CHAPTER XLVIII. 

NASO-PHARYNGEAL CATARRH. 

This condition is probably due to atrophic changes which 
take place in the pharyngeal tonsil in adult life. These 
cnanges consist in the disappearance of the cellular elements 
of the lymphatic nodules, and an increase in the fibrous tissue 
constituting the framework of the gland. It is probable that 
if the complete history of every case could be obtained we 
should find that these patients suffered from symptoms refer- 
able to a moderate hypertrophy of the pharyngeal tonsil dur- 
ing childhood. The condition, however, was not sufficiently 
marked to demand surgical interference, and in early adult 
life the symptoms disappeared. It is only late in life, when 
sclerotic changes take place, that symptoms dependent upon 
the presence of this tissue again appear. The prominent 
symptom of which these patients complain is the accumula- 
tion of viscid secretion in the pharyngeal vault. This secre- 
tion excites repeated efforts upon the part of the patient to 
draw the mass back into the mouth and expel it in this way. 
The annoyance which the condition occasions varies greatly 
in different individuals. In some, the effort to expel the in- 
spissated mucus may bring on an attack of retching, or even 
vomiting, while in other instances spasmodic attacks of cough- 
ing may be excited. All manifestations due to the presence 
of the mass are exaggerated when the patient suffers from a 
cold in the head, and each fresh attack of inflammation ren- 
ders the victim more liable to a succeeding attack upon slight 
exposure. 

The aural symptoms in general are those enumerated in 
the chapter upon Chronic Catarrhal Otitis Media. We may 
find either a hyperplastic or a hypertrophic process within 
the middle ear. It is a question to what extent the naso- 
pharyngeal condition has been productive of the aural lesion. 
My own belief is that the two processes are coexistent rather 
than interdependent, and that the middle-ear changes have 

(633) 



634 NASO-PHARYNGEAL CATARRH. 

resulted from the presence of an excessive amount of adenoid 
tissue in the pharyngeal vault at an early period of life, and 
do not depend upon the sclerotic changes which have subse- 
quently taken place in this tissue, although they are similar in 
character. Naturally the aural symptoms are aggravated by 
the congestion of the naso-pharyngeal mucous membrane, on 
account of the intimate relation which exists between the 
vessels in the two regions ; but it is unwarrantable to assume 
that any treatment directed toward a correction of the naso- 
pharyngeal lesion will do more than exempt the organ of 
hearing from repeated attacks of congestion. The sclerotic 
changes have advanced to such an extent in these cases that 
we can not hope for an absorption of the new tissue, even if 
the parts are kept in a state of perfect equilibrium. Efforts 
at treatment will cut short an attack of inflammation in this 
region and relieve the throat symptoms, and will at the same 
time relieve the acute aural symptoms and cause the tym- 
panic mucous membrane to return to the condition present 
before the acute attack. Beyond this, however, no treatment 
of the naso-pharynx will be of avail in adult life. 

The treatment of the condition consists in local applica- 
tions of an astringent solution to the naso-pharyngeal mucous 
membrane. These applications may be made by means of a 
curved applicator carried behind the soft palate, or, as I pre- 
fer, by a cotton-tipped probe carried through the anterior 
nares, the nasal mucous membrane having been previously 
anaesthetized with cocaine. The strength of the application 
should vary with the intensity of the inflammation. In the 
early stages a solution of nitrate of silver, thirty grains to 
the ounce, thoroughly applied to the naso-pharynx, may stop 
the progress of the attack completely. In the later stages a 
weaker solution should be employed. For the chronic con- 
dition relief is obtained by cleansing the naso-pharyngeal mu- 
cous membrane either by the post-nasal syringe or by means 
of a spray through the anterior nares ; after which the appli- 
cation of a solution of nitrate of silver, of a strength of from 
ten to fifteen grains to the ounce, applied in the manner 
already described, will frequently be of service in relieving 
the discomfort attendant upon the condition. 



INDEX. 



Abscess, cerebral, 459, 461, 530. 
diagnosis of, 461. 
prognosis of, 462. 
symptomatology of, 460. 
treatment of, 531. 
epidural, 529. 
extradural, 458. 
prognosis of, 459. 
symptomatology of, 458. 
treatment of, 459. 
of auricle, 201. 
Acoumeter of Politzer, 143. 

of Urbantschitsch, 146. 
Adenoid growths, 364, 629-631. 

tissue, 133. 
Adhesions, division of, 480, 481. 
Adults, symptoms of acute catarrhal otitis 

in, 325. 
Affections, aural, complicating, 592, 594. 
acute infectious diseases, 591. 
diabetes, 599. 
gout, 599. 
leucaemia, 597. 
metastasis, 595. 
nephritis, 594. 
rheumatism, 599. 
special drags, 600. 
tuberculosis, 596. 
dependent upon chronic visceral con- 
ditions, 594. 
Ampullae, the, 40. 
Anaesthesia, 468. 
Anatomy of the ear, 3. 
of the mastoid, 432. 
Angioma of the auricle, 209. 
Anomalies of the auricle, 173. 
of the antihelix, 174. 
of the antitragus, 175. 
of the helix, 174. 
of the lobule, 174. 
of the tragus, 175. 



Antihelix, anomalies of the, 174. 
Anton, 206. 
Antrum, the, 437. 

mastoid, the, 433, 434. 
Apparatus, auditory, concerted action of 
the, 66. 
conducting, the, 4. 
surgery of, 464, 465. 
lesions of, 155. 
investment, epithelial, of, 22. 
diseases of, 173 
Appendages, auricular, 178, 179. 
Aqueductus Fallopii, the, 12. 
Arch, Corti's, 41. 
Arteries, the, 28, 29, 44. 
Artery, cochlear, the, 45. 

internal auditory, the, 44, 45. 
internal maxillary, the, 29. 
occipital, the, 29. 
posterior auricular, the, 29. 
superficial temporal, the, 29. 
tympanic, or auricularis profunda, the, 

29, 30 
vestibular, the, 45. 
vestibulo-cochlear, the, 45. 
Articulation, the incudo-stapedial, 17, 
482. 
the malleo-incudal, 17. 
the stapedio-vestibular, 17. 
Aspergillus flavus, 247. 

glaucus, 246. 
Atheroma of auricle, 201. 
Attollens aurem, the, 27. 
Attrahens aurem, the, 27. 
Audition, disturbances of, in hysteria, 
605. 
in neurasthenia, 602. 
Auditory hyperesthesia, 71. 
Aural polypus, removal of, 407. 
specula, 85. 
speculum, improvised, 85. 



(635) 



6 3 6 



INDEX. 



Auricle, the, 4, 50. 
abscess of, 201. 

affections, inflammatory, of 200. 
angioma of, 209. 

treatment of, 209. 
atheroma of, 207. 

treatment of, 208. 
cystoma of, 210. 

treatment of, 211. 
deformities of, 174. 
diseases of, 173. 

cutaneous, of, 187. 
epithelioma of, 213. 

treatment of, 214, 215. 
erysipelas of, 201. 
fibroma of, 206. 

treatment of, 207. 
framework, cartilaginous, of, 4. 
gangrene of, 205. 

treatment of, 205. 
hematoma of, 202. 

treatment of, 203. 
lipoma of, 207. 
malformations congenital, of, 173. 

treatment of, 180. 
, malposition, of the entire, 176. 
ossification, of, 204. 

treatment of, 205. 
papilloma of, 212. 
perichondritis of, 200. 

treatment of, 201. 
sarcoma of, 216. 

treatment of, 216. 
shape, anomalous, of, T76. 
treatment of injuries of, 184. 
tumors, benign, of, 206. 

malignant, of, 213. 
wounds and injuries of, 183. 

treatment of, 184. 
Auricular appendages, 178, 179. 

artery, the posterior, 29. 
Auscultatory sounds, 113. 

Bacon's scarificator, 227. 
Bag, air, of Politzer, 329. 
Bag, Politzer's, 109. 
Baginsky, 59. 
Baratoux, 196. 
Barth, 145, 178. 
Basilaris, membrana, the, 41. 
Bergmann, 461. 
method of, 526. 



Bezold, 62, 150. 
Binder, 175. 

Bing, experiment of, 162. 
Blake, 26, 100, 144, 409. 
Blake's middle-ear syringe, 334. 
Bloodletting, 227. 
Boettecher, 44. 
Bone conduction, 151. 
temporal, the, 437. 
development of, 8. 
Bony canal, the, 7. 
Bosworth, 135, 620, 624, 629. 
Botey, 100. 

Bougie, Eustachian, the, 309,- 381. 
Brenner, 167. 
Brown-Sequard, 202. 
Bruit, the normal tympanic, 114. 
Brunner, 202. 
Bryant, 26. 
Buck, 212, 356. 
Burnett, 180. 

Canal, bony, the, 7. 

bodies, foreign, in, 279. 
aetiology of, 279. 
diagnosis of, 281. 
pathology of, 279. 
prognosis of, 281. 
symptomatology of, 280. 
treatment of, 282, 283. 

by external operation, 283. 
cochlear, the, 37. 

Eustachian, the, 297, 331, 365, 381, 
610. 
dilatation of, 366. 
Fallopian the, 12, 508. 
Canals, semicircular, the, 35, 60. 
Cantharidis acetum, application of, 192. 
Cassebohm, 356. 
Catarrh, Eustachian, 300, 306. 
naso-pharyngeal, 633, 634. 
tubal, 300. 

aetiology of, 300. 
diagnosis of, 302, 303. 

examination, functional, 304, 305. 
examination, physical, 302. 
pathology of, 300. 
prognosis of, 306. 
symptomatology of, 301. 
treatment of, 307, 309, 31 1, 
tubo-tympanic, 313. See CONGESTION, 

TUBO-TYMPANIC. 



INDEX. 



6?>7 



Catheter, Eustachian, the, 107, 303, 307, 
30S, 319, 335, 365, 386. 
introduction of, 112. 
of Noyes, 124. 
ordinary, 309. 
Pom'eroy's faucial, 125. 
Catheterization, 107, III. 
dangers of, 129. 
methods' of, 119, 121. 
obstacles to, 122, 123, 125, 127. 
value, comparative, of, 130, 131. 
Cavity, tympanic, the, 12, 13, 435. 

preparations preliminary to opera- 
tions upon, 465. 
Cells, hair, the, 39. 
Cells of Deiters, 42. 
Cerebral abscess, 459, 461, 530. 
diagnosis of, 461. 
prognosis of, 462. 
symptomatology of, 460. 
treatment of, 531. 
Cerumen, impacted, 267, 280. 
aetiology of, 267. 
diagnosis of, 271. 
pathology of, 268. 
prognosis of, 272, 273. 
symptomatology of, 269. 
treatment of, 274, 275, 277. 
Chain, ossicular, the, 52. 

operations involving, 470, 482. 
removal of, 485. 
Changes circulatory, phenomena depend- 
ent upon, 68. 
developmental, 437. 
Channel, Eustachian, 120. 
Chatellier, 193. 

Cheyne-Stokes respiration, 453. 
Children, symptoms of acute catarrhal 

otitis in, 326, 327. 
Chimani, 209. 
Cholesteatoma, 391. 
development of, 425. 
operation for, 524. 
Cholewa, 231, 369, 477. 
Cleveland, 68. 
Cocaine, use of, 128. 
Cochlea, the, 35, 57. 
function of, 57, 59. 
membranous, 40, 41. 
Cochlear artery, the 45. 

canal, the, 37. 
Coil, Leiter, the, 450. 



Cold, 229. 

Color of the membrana tympani, 92. 
Complications, intracranial, 441. 
Concussion of the labyrinth, 544. 
Conduction, bone, augmentation of, 160. 
Congestion, tubal, 300, 

aetiology of, 300. 

diagnosis of, 303. 

examination, functional, 304, 305. 
examination, physical, 302. 

pathology of, 300. 

prognosis of, 306. 

symptomatology of, 301. 

treatment of, 307, 309, 311. 
tubo-tympanic, 313. 

aetiology of, 313. 

diagnosis of, 315, 317. 

pathology of, 313. 

prognosis of, 318. 

symptomatology of, 314. 

treatment of, 319, 321. 
Corradi, 66. 
Corti, arch of, 41, 44.. 
fibres of, 42. 
membrane of, 43. 
rods of, 41, 58. 
Cough, reflex, 270. 
Cranial contents, relations of, 435. 
Cristas acusticse, the, 40. 
Croupous otitis, external, 261. 
Curette, use of the, 277. 
Cutogno, recessus of, 38. 

Deaf-mutism, 614. 

diagnosis of, 616. 

pathology of, 614. 

prognosis of, 617. 

symptomatology of, 616. 

treatment of, 617. 
Deafness, catarrhal, 351. 
Deiters, cells of, 42. 
Delstanche, masseur of, 381. 
De Rossi, 189. 
Diabetes, 599. 
Diagnosis, differential, 155. 
Diphtheria, 577. 

Diphtheritic otitis, external, 261. 
Disarticulation at the incudo-stapedial 

joint, 482. 
Diseases, aural, complicating, 590, 591. 

of the auricle, 173. 

of the external canal, 217. 



6 3 8 



INDEX. 



Diseases, of the mastoid, 439. 
of the middle ear, 296. 
of the perceptive mechanism, 535. 
Disturbances, reflex aural, 608, 609, 612. 
prognosis of, 611. 
treatment of, 611. 
Division of adhesions, 481. 

about stapes, 480. 
Dobell, fluid of, 365. 
Drainage, 349. 

Drum membrane, normal appearance of 
the, 92. 
recognition of the, 89. 
retraction of the, 339, 377. 

Ear, anatomy of the, 3, 4, 33. 
Darwinian, the, 174. 
internal, the, 34. 
middle, diseases of the, 295. 
physiology of the, 48. 
preparation of the, 467. 
syringe, 234. 
Earache, 329, 
Ears, frozen, 186. 
Eczema, 188, 189. 

treatment of, 189, 191. 
Eitelberg's test, 169. 
Embolism, labyrinthine, 551, 552. 
aetiology of, 551. 
pathology of, 551. 
prognosis of, 552. 
symptomatology of, 551. 
treatment of, 552. 
Eustachian tube, the, 318. 
occlusion of, 314, 316. 
Ewald, 61. 

Examination, functional, 142, 317, 330, 
342, 362, 378, 379, 427. 
physical, 73, 315, 328, 329, 340, 358, 
361, 339, 377- 
obstacles to, 95. 
technique of, the, 86, 87, 89. 
Extradural abscess. See Abscess. 

Fallopii, aquaeductus,the, 32,438, 523, 570. 
Fever, involvement of perceptive appara- 
tus in typhoid, 576. 
in typhus, 576. 
Fibres of Prussak, 92. 
Fissure, Glaserian, the, 16, 18, 29, 33. 

Rivinian, the, 248. 
Fistula, auricular, 179. 
congenita auris, 178. 



Flesch, 202. 
Fluid, removal of, 367. 
Folds, intratympanic, the, 25. 
Forceps, McKay's ear, 489. 
Fork, tuning, of author, 148. 

of Bezold, 157. 

of Blake, 157. 
Forks, tuning, Hartmann's series of, 157, 

158. 
Fossa of Rosenmuller, 138. 
Fowler, solution of, 542. 
Fungus, development of a, 241. 
Furuncle, 217. 

Gad, 54, 65. 

Galton whistle, the, 149, 150, 155, 156, 
158, 159, 3i8, 616, 617. 
modified, 157. 
Galvanic reaction of the auditory nerve, 

167, 169. 
Ganglion, Meckel's, 32. 
Gardiner Brown, 154. 
Gelle's test, 163. 

Gout, aural manifestations of, 599. 
Gradinego, 146, 160, 165, 174. 

test of, 164, 165, 169. 
Green, 194, 477. 
Gruber, 230, 265, 475, 477. 
Gruening, 452. 

Haemorrhage, labyrinthine, 548. 

aetiology of, 548. 

diagnosis of, 549. 

pathology of, 548. 

prognosis of, 550. 

symptomatology of, 549. 

treatment of, 550. 
Hartmann, 211, 260. 
tenotome of, 477. 
tuning forks of, 157, 158. 
Haug, 207. 
Hearing, qualitative determination of, 155. 

quantitative determination of, 142. 
Heat, 231. 

Helix, anomalies of the, 174. 
Helmholtz, 59. 

Hensenii, canalis reuniens, the, 37, 40. 
Herpes of the auricle, 193. 

treatment of, 194, 195. 
History, the, 139-141. 
Homell's method, 382. 
Hutchinson teeth, 554. 



INDEX. 



639 



Hyperemia of the labyrinth, 544. 
aetiology of, 544. 
diagnosis of, 545. 
pathology of, 545. 
prognosis of, 546. 
symptomatology of, 545. 
treatment of, 546. 
Hyperesthesia, auditory, 71. 
Hyrtl, 476. 

Hysteria, aural manifestations of, 605. 
diagnosis of, 606. 
prognosis of, 607. 
symptomatology of, 605. 
treatment of, 607. 

Incision of membrana tympani, 319, 331, 

345, 469, 47i, 473- 
Incus, the, 17, 394. 
caries of, 389. 

division of the long process of, 482. 
ligaments of, 18. 
obstacles to the removal of, 503, 505, 

507, 509. 
plastic operations upon, 484. 
removal of, 491, 493. 
Inflammation tympanic, intracranial com- 
plications of, 453. 
diagnosis of, 454. 
prognosis of, 454. 
symptomatology of, 453. 
treatment of, 454. 
Inflation, 307, 319, 365. 

methods of, 103. 
Influenza, epidemic, effect upon percep- 
tive apparatus, 577. 
Instillations, 229, 331. 
Instruments, preparation of, 138, 139. 
Internal maxillary, tympanic branch of 

the, 29. 
Intertrigo, 187. 

treatment of, 188. 
Intracranial involvement, 441, 443. 
Intratympanic folds, the, 25. 

soft parts, operations involving the, 469. 
Investment, epithelial, of the conducting 

apparatus, 23. 
Irrigation, 333, 335. 
Itelberg's test, 164. 

Jankau, 166, 167. 

Joint, incudo-stapedial, the, 17. 

disarticulation at, 482. 
Jungken, 209. 



Kaffirs, development of the lobule among 

the, 174. 
Kaiser, 39. 
Kessel, 485, 494. 
Kipp, 207, 209. 
Knapp, 459. 
Konig's rods, 150. 
Korner, 435, 462. 
Kosegarten, 386. 
Kretschmann, 506. 

Labyrinth, the, 57. 
anaemia of, 541. 
aetiology of, 541. 
diagnosis of, 542. 

examination, functional, 542. 
examination, physical, 542. 
prognosis of, 542. 
symptomatology of, 541. 
treatment of, 542. 
blood supply of, 44. 
bony, the, 34, 35. 

effect of tympanic changes upon, 61, 63. 
hyperaemia of, 544. 
aetiology of, 544. 
diagnosis of, 545. 

examination, functional, 545. 
examination, physical, 545. 
pathology of, 544. 
prognosis of, 546. 
symptomatology of, 545. 
treatment of, 546. 
inflammation, acute of, in acute tym- 
panic inflammation, 569. 
aetiology of, 569. 
diagnosis of, 571. 

examination, functional, 571. 
examination, physical, 571. 
pathology of, 569. 
prognosis of, 572. 
symptomatology of, 570. 
treatment of, 572. 
inflammation, acute of, in acute men- 
ingitis, 581. 
in epidemic meningitis, 577. 
in mumps, 576. 
inflammation, chronic of, secondary to 
chronic tympanic disease, 557. 
diagnosis of, 562. 

examination, functional, 563. 
examination, physical, 562. 
prognosis of, 564. 



640 



INDEX. 



Labyrinth, symptomatology of, 558, 559, 
561. 
treatment of, 565, 567. 
inflammation, chronic of, in leucaemia, 

597- 
inflammation, specific, of, 553, 554. 
aetiology of, 553. 
diagnosis of, 554. 
pathology of, 553, 557- 
prognosis of, 554. 
symptomatology of, 553. 
treatment of, 555. 
membranous, the, 37. 
Labyrinthine complications of, chronic 
hypertrophic otitis media, 355. 
degeneration, 379. 
fluid, the, 429. 
haemorrhage, 548. 
aetiology of, 548. 
diagnosis of, 549. 
pathology of, 548. 
prognosis of, 550. 
symptomatology of, 549. 
treatment of, 550. 
involvement, 374, 378, 385, 395. 
Lamina spiralis, the, 35. 
Landmarks at the fundus of the canal, 90. 
Landmarks, intratympanic, the, 360. 
Leech, author's artificial, 228. 
Leiter coil, 228, 229, 253, 259, 346. 
Leucaemia, 597, 
Levator palati, the, 28. 
Ligament, anterior, of the malleus, 18. 
division of, 479. 
external, of the malleus, 18. 
posterior, of the incus, 18. 

of the malleus, 18. 
superior, of the malleus, 18. 
Ligaments, interossicular, the, 19. 
intratympanic, the, 19. 
of the stapes, 19. 
Light, the source of, 76, 77. 
Listerine, 365 

Lobule, anomalies of the, T74. 
thickening of the, 204. 

treatment of, 204. 
tumor, sebaceous, of the, 208. 
Loewenberg, 218. 
Lucae, 165, 382, 486. 
bulb of, 311. 
phonometer of, 147. 
pressure sound of, 383. 



Ludewig, 411, 412, 507, 509. 

Lupus erythematosus of the auricle, 197. 

treatment of, 198. 
vulgaris, 198. 

treatment of, 198, 199. 
Lustre of the drum membrane, 92. 
Lymphatics of the conducting apparatus, 

31- 
Lymphatism, 629. 

Macewen, 454, 462. 
Macula acustica, the, 39. 
Malleus, the, 14. 

division of anterior ligament of, 479. 
ligaments of the, 17. 
removal of the, 489. 
rotation of the, 358. 
Manubrium mallei, the, 398. 

excision of a portion of, 482. 
Marian, 208. 
Massage, 382, 383. 
Mastoid, the, 401. 
diploic, 433. 
diseases of, 432. 
involvement of, 347. 
oedema over, 224. 
operation upon, 515, 517. 

technique of, 519, 521, 523, 525. 
the pneumatic, 432. 
Mastoid process, anatomy of the, 432. 
diseases of the, 432. 
inflammation of the, 439. 
aetiology of, 439. 
diagnosis of, 445, 447. 
pathology of, 440. 
prognosis of, 448. 
symptomatology of, 442, 443. 
treatment of, 449, 451. 
Mastoiditis, primary, 439. 
Maxillary artery, the internal, 29. 
Measures, precautionary, in examination, 

159- 
Meatus, the bony, 9, n. 

external auditory, diseases of the, 217. 
(See Otitis, external.) 
exostoses of the, 285. 

aetiology of, 285. 

diagnosis of, 286. 

pathology of, 285. 

prognosis of, 287. 

symptomatology of, 286. 

treatment of, 288, 289. 



INDEX. 



641 



Meatus, epithelioma of the, 213. 
treatment of, 214, 215. 
malignant tumors of the, 213. 
sarcoma of the, 216. 
treatment of, 216. 
the cartilaginous, 6. 
Mechanism, perceptive, diseases of the, 

535. 537- 
involvement of the, 574, 578, 581, 582. 

diagnosis of, 575. 

in acute meningitis, 5 Si. 

in epidemic meningitis, 577. 

in mumps, 576. 

in typhoid fever, 576. 

in typhus fever, 576. 

pathology of, 574. 

prognosis of, 575. 

symptomatology of, 575. 

treatment of, 575. 
the receptive, 33. 
Media, scala, the, 40. 
Medical Sciences, Reference Handbook 

of, 507. 
Membrana basilaris, the, 41. 

recticularis, the, 43. 
Membrana tympani, the, 57, 91, 93. 
bulging of, 317, 328, 341. 
depression of, 358. 
destruction of, 395. 
excision of large part of, 482. 
function of, 51. 
incision of, 319, 331, 332, 345, 469-471, 

473- 
injuries of, 291. 
aetiology of, 291. 
diagnosis of, 293. 
pathology of, 291. 
prognosis of, 294. 
symptomatology of, 292. 
treatment of, 294, 295. 
method of incising, 321, 472. 
mobility of, 100. 
multiple incision of, 475. 
operations involving, 469, 470. 

plastic, uniting incus or stapes to, 
484. 
pockets of, 24. 
retraction of, 383. 
rupture of, 293. 
technique of removal of, 486. 
Membrana vibrans, the, 99, 396. 
Membrane, partially destroyed, technique 
43 



of operation for excision of rem- 
nant, 500. 
Membrane, reproduction of the, 497. 

treatment of, 499. 
Meningitis, acute, involvement of percep- 
tive apparatus in, 581. 
diagnosis of, 583. 

examination, functional, 583. 
pathology of, 581. 
prognosis of, 584. 
symptomatology of, 581. 
treatment of, 584. 
epidemic, cerebro-spinal, 577. 
diagnosis of, 579. 

examination, functional, 579. 
examination, physical, 579. 
pathology of, 577. 
prognosis of, 579. 
symptomatology of, 578. 
treatment of, 580. 
otitic, 455. 
purulent, 532. 

treatment of, 533. 
Metastasis, 595. 
Meyer, 632. 
Microtia, 176, 177. 

Middle ear, treatment of discharge from, 
409. 
operations on the, 465. 
classification of, 469. 
instruments for, 466. 
treatment after, 495. 
Miot, 484. 
Mirror, reflecting, the, 78, 81. 

rhinoscopic, the, 138. 
Modiolus, the, 35. 
Motion, passive, 381. 
Mucous membrane, reduplications of, 24. 
Mumps, 576. 

Muscles, the extrinsic, 27. 
function of the, 55. 
• the intratympanic, 27. 
the intrinsic, 27. 
the tubal, 28. 
Myringectomy, partial, 474. 
Myringotomy, 469, 470. 
exploratory, 473. 
operation of, 471. 

Naso-pharynx, diseases of the, 618, 619. 

examination of the, 132. 
Nephritis, aural complications of, 594. 



642 



INDEX. 



Nerve, auditory, the, 45, 47. 
galvanic reaction of, 167. 
reaction of, to stimuli, 65. 

auricularis magnus, the, 31. 

auriculotemporal, the, 31. 

cochlear, the, 45. 

facial, the, 31. 

trigeminus, the, 31. 

vagus, auricular branch of the, 31. 

vestibular, the, 46. 

Vidian, the, 32. 
Nerves, the sensory, 31. 
Nervous diseases, effect of, 586. 
Neurasthenia, aural manifestations of, 
602. 

diagnosis of, 603. 

prognosis of, 605. 

treatment of, 605. 
Nose, diseases of the, 618, 619. 

examination of the, 132. 

Observations, preliminary, 73, 75,. 297^ 

299. 
Oliver, 68. 
Operation, mastoid, the, 515. 

preparation of the field of, 467. 
Operations, middle-ear, 476. 
Orifices, Eustachian, the, 630. 
Ossicles, the, 14, 15, 17, 398, 408. 
function of, 53. 
mobility of, 100. 
removal of, 485, 487. 
removal of individual, 485. 
technique of removal of, 486. 

of removal of, with membrana tym- 
pani intact, 486. 
Ostmann, 24. 

Otitis external circumscribed, acute, 
217. 
aetiology of, 217. 
diagnosis of, 221, 223. 
pathology of, 218, 219. 
prognosis of, 225. 
symptomatology of, 219. 
treatment of, 226, 227, 229, 231, 233, 

235- 
Otitis external circumscribed, chronic, 
236, 237. 
incision of, 233. 
internal medication of, 235. 
Otitis external croupous, treatment of, 
263. 



Otitis external diffuse, acute, 255. 

aetiology of, 255. 

diagnosis of, 256, 257. 

pathology of, 255. 

prognosis of, 258. 

symptomatology of, 256. 

treatment of, 258, 259. 
Otitis external diffuse, chronic, 238. 

aetiology of, 238, 239. 

diagnosis of, 244, 245, 247. 

pathology of, 239, 241. 

prognosis of, 249. 

symptomatology of, 242, 243. 

treatment of, 250, 253,- 257. 
diphtheritic external, treatment of, 263. 
Otitis, external, haemorrhagic, 265. 

treatment of, 266. 
Otitis media, acute catarrhal, 323. 

aetiology of, 323. 

diagnosis of, 328, 329. 

pathology of, 324, 325. 

prognosis of, 330. 

symptomatology of, 324, 327. 

treatment of, 331, 333, 335. 
chronic, 351, 633. 

diagnosis of, 376. 
Otitis media, chronic hyperplastic, 372. 

aetiology of, 372. 

diagnosis of, 376, 377, 379. 
functional examination, 378. 
physical examination, 376. 

pathology of, 373. 

prognosis of, 380. 

symptomatology of, 374, 375. 

treatment of, 381, 383, 385. 
chronic hypertrophic, 352. 

aetiology of, 352, 353. 

diagnosis of, 358, 359, 361. 
functional examination, 362. 
physical examination, 358. 

pathology of, 354, 355. 

prognosis of, 363. 

symptomatology of, 356, 357. 

treatment of, 364, 365, 367, 369, 

37i- 
Otitis media, acute purulent, 336. 
aetiology of, 336. 
diagnosis of, 340, 341. 
pathology of, 337. 
prognosis of, 343. 
symptomatology of, 339. 
treatment of, 344, 345, 347, 349. 



INDEX. 



64: 



Otitis media, chronic purulent, 388. 
aetiology of, 38S. 
diagnosis of, 395, 397, 399. 
functional examination, 399. 
physical examination, 395, 397. 
pathology of, 38S-391. 
prognosis of, 400, 401. 
symptomatology of, 392, 393. 
treatment of, 402. 
Otitis media purulenta residua, 416. 
acute cases, 416. 
aetiology of, 416. 
diagnosis of, 418, 419. 
pathology of, 416. 
prognosis of, 419. 
symptomatology of, 417. 
treatment of, 420, 421. 
chronic cases, 422. 
diagnosis of, 426. 

functional examination, 426. 
physical examination, 426. 
pathology of, 423. 
prognosis of, 427. 
symptomatology of, 425. 
treatment of, 428, 429. 
Otoliths, 40. 

Otomycosis, characteristics of, 242. 
Otorrhcea, therapeutic measures in, 415. 
operative procedures for, 411. 
temporary, 413. 
treatment after operation, 413. 
Otoscope, the pneumatic, 101, 361. 
Siegle's, 101, 381-383. 

Palati, levator, the, 28. 

tensor, the, 28. 
Panotitis, 569. 
Paresthesia, 71. 
Passages, upper air, examination of the, 

133, 135, 137- 
Patient, position of the, 469. 
Pemphigus, 193. 

treatment of, 193. 
Perichondritis, deformity following, 200. 
Petrosal, the great deep, 32. 

the great superficial, 32. 

the small deep, 32. 

the small superficial, 32. 
Pniiger, 179. 
Pharyngeal sounds, 118. 
Pharynx, examination of, 132. 
Phenomena, 68. 



Phenomena, irregular, 161. 

reflex, 67. 

secondary, 68, 69. 
Pierson's solution, 542. 
Plexus, tympanic, the, 32. 
Plicotomy, 371, 476. 
Pocket of Troelsch, 342. 
Politzer, 265, 303, 305, 307, 312, 317, 319, 
321, 340, 356, 382, 3S6, 475, 477, 
479. 548, 557, 617. 
Politzerization compared with catheter- 
ization, 131. 

comparative value of, 130. 
Polyotia, 180. 

treatment of, 181. 
Polyp aural, differentiation from, 338. 

removal of, 406, 407. 
Pomeroy, 154, 359, 477. 
Pons Varolii, 45. 
Powders, insufflation of, 405, 628. 
Prophylaxis, 311. 
Prussak, 31. 

chamber of, 25. 

fibres of, 23. 

space of, 23. 

Quinine, 543. 

Randall, 435. 

Reissner, membrane of, 37, 40. 

Respiration, Cheyne-Stokes, 453. 

Retrahens aurem, the, 27. 

Reticularis, the membrana, 43. 

Rheumatism, aural complications of, 

599- 
Rhinitis, atrophic, 626, 627. 
Rhinitis, hypertrophic, 620, 622, 623. 
Ridge, temporal, the, 436. 
Rinne, experiment of, 163, 304, 563. 

test of, 163, 152, 153, 304. 
Rivinian fissure, the, 248. 

segment, the, 97, 240, 336, 447. 
Rods, of Koenig, 150. 
Rohrer, 163. 
Roosa, 31 1. 

Rosenmuller, fosra of, 138. 
Rudinger, 38. 

Saccule, the, 39. 

Salpingitis, acute, 300. See Congestion, 

tubal. 
Santorini, incisures of, 7. 



644 



INDEX. 



Scale, the Galton, 606. 

Scalpel, 515. 

Schimmelbusch, 218. 

Schubert, 174. 

Schvvabach, 154. 

Schwartze, 358, 452, 477, 485. 

Septum nasal, deformities of the, 620, 

624, 625. 
Sexton, 499. 

Shrapnell, membrane of, 287, 293, 328, 
342, 378, 396, 449, 488. 
incision of, 472. 
Siebenmann, 144, 161, 251. 
Siegle's otoscope, 101, 381, 383. 
Sinus, the lateral, 435. 
thrombosis of, 455, 528. 
diagnosis of, 457. 
prognosis of, 457. 
symptomatology of, 456. 
treatment of, 457, 529. 
Society, transactions of the American 

Otological, 512. 
Sound, 49. 

Sounds, auscultatory, 113. 
pharyngeal, 118. 
tympanic, 114, 115. 
tubal, 116, 117. 
Specula, aural,' 83, 85. 
Speculum, Bosworth's nasal, 135. 

pneumatic, the, 101. 
Spray, alkaline, 627. 
Stacke, 509, 526. 
Stapedectomy, 510, 511, 513. 

when the membrana tympani is intact, 

510. 
when the membrane is partially de- 
stroyed, 511. 
Stapedius, the, 28. 
Stapes, the, 17, 398, 401. 
disarticulation of, 483. 
mobility of, 384. 
mobilization of, 482, 483. 
plastic operations upon, 482. 
region of, 424. 
Steinbruegge, 160. 
Stetter, 174. 

Substances, medicinal, 600. 
Support, mechanical, of relaxed mem- 
brana tympani, 371. 
Suppuration, aural, surgical treatment of 
the intracranial complications of, 
527. 



Syphilis, of auricle, 195. 
treatment of, 197. 

of labyrinth, 553. See Labyrinth. 
Syringe, Blake's middle-ear, 334. 

hard-rubber ear, 234. 
Syringing, technique of, 275, 403. 
Szenes, 175. 

Taylor, 196. 

Tectoria, the membrana, 43. 
Teeth, Hutchinson, 554. 
Temporal ridge, the, 436. 
Temporal, the superficial, 29. 
Tenotome, Hartmann's, 477. 
Tensor palati muscle, the, 28. 

tympani muscle, the, 27. 

tenotomy of, 369, 476, 469, 477. 
Tests, qualitative, 149. 

quantitative, 142, 143, 145, 147, 148. 
Teutleben, 24. 
Thiersch, method of skin grafting of, 

215. 

solution of, 368. 
Thrombosis, labyrinthine, 551. 
aetiology of, 551. 
pathology, of, 551. 
prognosis of, 552. 
symptomatology of, 551. 
treatment of, 552. 
Thrombosis of lateral sinus. See Sinus. 
Tonsils, faucial, the, 365. 

enlarged, 404. 
Tongue depressors, 137. 
Topography, tympanic, 97, 99. 
Tragus, anomalies of the, 175. 
Troelsch, pocket of, 342. 
Tubal congestion, 300. See Congestion. 

sounds, 116. 
Tube, Eustachian, the, 19, 138, 295, 308, 
309, 320, 323, 324, 336, 354, 355, 
357, 361, 367, 368, 370, 374, 38i, 
3:9, 408, 428, 446, 486, 560, 595, 
596, 621. 
auscultation of, 103. 
catheterization of, 107. 
changes in, 352, 358. 
closure of, 305, 325. 
congestion of, 161, 352. 
muscles of, 28, 55. 
oedema of, 161. 
walls of, 357. 
Tuberculosis, aural lesion in, 439, 596. 



INDEX. 



645 



Tubo-tympanitis, acute, 313. See Con- 
gestion, TUBO-TYMPANIC. 
Tuning fork, the, 148. 
of author, 148. 
of Blake, 157. 
series of Hartmann, 158. 
Turbinated bodies, the, 620. 

hypertrophy of, 364, 404, 620. 
treatment of, 623. 
Tympanic inflammation, intracranial com- 
plications of, 453. 
plexus, 32. 
sounds, 114. 
topography, 97. 
vault, irrigation of, 410. 
Tympani, membrana, the, 21. 

scala, the, 45. 
Tympanum, inflation of the, 102, 103, 
436. 

Urbantschitsch, 159, 169, 179, 218. 

electric acoumeter of, 146. 
Utricle, the, 39. 

Valsalva's method of inflation, 161, 420. 
Vapors, use of, 309. 
Vault, of the tympanum, 13. 
irrigation of, 410. 



Vegetations, adenoid, 629, 630, 631. 
Veins of the conducting mechanism, 30. 
Veins of the labyrinth, 44. 
Vidian nerve, the, 30. 

Wagenshauser, 174, 194. 

Walb, 374. 

Wall, internal tympanic, the, 12, 14. 

Weber, 154, 158. 

modification of experiment of, 162. 
W T eber, F. E., 476. 
Weber-Liel, 369, 477. 
Weber's test, 151. 
Weil, 202. 
Wharton Jones, 69. 

Whistle, the Galton, 149, 150, 155, 156, 
318, 616, 617. 
author's modification of, 156. 
Wilde's incision, 347, 422, 450. 
Willisii, paracusis, 564, 583. 
Window, the oval, 424. 
Wounds, contused, of auricle, 185. 
Wreden, 482. 

Yearsley, 632. 



Ziicker, 195. 
Ziickerkandl, 



26, 30. 



THE END. 



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